1. Genitourinary Trauma TIM EVANS VIRGINIA COMMONWEALTH UNIVERSITY
January 28, 2015

2. Background
If injury to GU system identified, multi-organ injury is the rule.
Examples:
If renal injury found following penetrating trauma, 80-95% chance of other significant injury
If renal injury found following blunt trauma, 75% chance of other significant injury found
Other injuries may be more immediately life threatening and therefore
GU injury diagnosis may be overlooked or delayed

3. Case
Patient #1 is a 25 year old male is struck in the flank with a baseball bat. His systolic blood pressure is always above 100 mm Hg and his exam is only remarkable for a flank hematoma without abdominal tenderness. His urinalysis shows no RBCs.
Patient #1 got pissed off at the guy who hit him so he shot Patient #2 in the flank. Patient #2 is hemodynamically stable and does not have any RBCs in his urine
Two Questions:
Do either of these reprobates need imaging?
Do we need more bat control legislation?

4. Renal Trauma Most common GU injury—65% of GU injuries
10% of abdominal injuries involve the kidneys
Mechanism
80-95% due to blunt force—MVC, falls, assaults, sporting events

5. Renal Anatomy Retroperitoneal
Adjacent to lower two thoracic and first four lumbar vertebrae
Upper poles protected by ribs so lower poles more commonly injured
Right kidney inferior to left and more commonly injured
Kidney mobile, hilum more fixed—concern with shearing injury with deceleration

6. When are you concerned about renal injuries?
Mechanism of Injury
Penetrating injuries of abdomen, back or flank
Deceleration injuries
Physical exam
Tenderness of abdomen or flank
Ecchymosis of abdomen or flank
Xray
Fractures of lower ribs, thoraco-lumbar spine

7. When are you concerned about renal injuries?
Hematuria—over 95% of patients with renal trauma will have some degree of hematuria (>5 rbc/hpf)
THE PRESENCE OR DEGREE OF HEMATURIA DOES NOT CORRELATE WITH THE SEVERITY OF THE INJURY
25% of patients with gross hematuria have minor injuries
40% of the most serious renal injuries do not have any hematuria

8. Indications for imaging for renal trauma
Penetrating trauma in proximity to kidneys—the presence or absence of hematuria in penetrating trauma not predictive of injury, location of wound is most important factor
Gross hematuria
Microscopic hematuria (>3-5 RBC/HPF) with hemodynamic instability—systolic BP<90 at any time
Persistent microscopic hematuria
?Significant deceleration mechanisms
?Proximal injuries with blunt mechanisms
Mee SL, et al: Radiographic Assessment of Renal Trauma: A ten-year prospective study of patient selection. J Urol 141:1095, 1989

9. When not to image in patients with concern for renal trauma
Patients with microscopic hematuria who have always been hemodynamically stable
Patients who are not hemodynamically stable

10. No significant renal injuries missed
Microhematuria and no shock
Gross hematuria or
Microhematuria and shock (SBP<90 mmHg) all imaged-422
Imaged-
Significant injury 3
Significant renal injuries 78
Imaged-
Contusion
581
Without
Imaging
1004
1 renal repair
Renal repair 34
No significant renal injuries missed
Miller KS, McAninch JW: Radiographic assessment of renal trauma. Our 15-year experience. J Urol 1995;154:

11. Imaging techniques
Contrast enhanced CT—the best test, up to 98% accurate, not great for renal vein injuries
IVP—perhaps useful in the OR to determine function of contralateral kidney before contemplated nephrectomy
Angiography—better than CT for defining injuries to renal artery and vein, also used therapeutically to embolize or stent artery injury
Ultrasound—30% false negative rate for injury, used to look for two kidneys, free fluid
Contrast Enhanced Ultrasound—perhaps
MRI—not first line due to time, sensitivity similar to CT, can be used for follow up studies

12. AAST Kidney Injury Severity Scale

13. AAST Kidney Injury Severity Scale—Revision 2011
Grade IV - originally encompassed contained injuries to the main renal artery and vein, and collecting system injuries. Revision: adds segmental arterial and venous injury, and laceration to the renal pelvis or ureteropelvic junction. Multiple lacerations into the collecting system used to be considered a shattered kidney (Grade V), but now remains Grade IV.
Grade V - originally included main renal artery or vein laceration or avulsion, and multiple collecting system lacerations (shattered kidney). The revised classification includes only vascular injury (arterial or venous) and includes laceration, avulsion or thrombosis.

14. Grade I-Renal contusion

15. Grade I-Subcapsular Hematoma

16. Grade II-Small Cortical Laceration

17. Grade III-Major Renal Laceration

18. Grade IV-Major Laceration involving Collecting System

19. Grade IV- Multiple Renal Lacerations

20. Grade IV-“Shattered” Kidney

21. Grade V- Avascular Left Kidney

22. Injury in proximity to kidney Hematuria (Gross or microscopic)
Trauma
Penetrating
Blunt
Injury in proximity to kidney
Hematuria (Gross or microscopic)
Associated with shock
(SBP <90)
Hematuria
Microscopic (>5 RBC/HPF)
No shock
Unstable
Stable
Image with concern for other organs
Abdominal exploration
CT scan with IV contrast
Single-shot
IVP on table
Grades III-V
Clinical
follow-up
Abnormal or inconclusive
Selective renal
exploration
Renal exploration

23. Management of Renal Injuries
Grade I—home
Grade II-IV—admit, observe
Grade V—observe, vascular repair/stent, or nephrectomy
Only absolute indications for surgery are persistent renal bleeding with hemodynamic instability, active extravasation of IV contrast, expanding or pulsatile perirenal hematoma suggesting Grade V vascular injury

24. Complications of Renal Injuries
Mortality 3%
Complications
First six weeks
Hemorrhage/shock
Sepsis/abscess
ATN
Late
Renovascular HTN 1-4%

25. CASE
30 year old s/p cystoscopic removal of distal ureteral stone. Now with flank pain and nausea. T 39 C, diffuse abdominal and flank tenderness noted.
U/A--negative
Diagnosis? Studies?

26. Ureteral Trauma Accounts for 1% of urologic trauma
Most commonly iatrogenic following GU, gynecologic, vascular or colorectal surgery
If following external trauma, 80-95% due to penetrating mechanism, usually GSW

27. Ureteral Anatomy
Thin, mobile tubes running between renal pelvis and posterior superior angle of bladder
Retroperitoneal in abdomen
Protected from injury by size and mobility

28. When are you concerned about ureteral injuries?
Recent GU, gynecologic, vascular or colorectal procedure
Penetrating (usually GSW) trauma to abd, back, flank
Deceleration mechanisms
Suspicion raised with injuries to iliac vessels, urinary bladder, sigmoid colon, thoracolumbar dislocations, lumbar spine (including process) fractures

29. Hematuria following ureteral injuries
Ureteral injury following iatrogenic cause—10-15% of patients with hematuria
Hematuria absent in 30-60% of identified ureteral injuries from external violence
Hematuria following penetrating trauma—a study of 71 ureteral injuries
32% without hematuria
40% with gross hematuria
28% with microscopic hematuria
Brandes SB, et al: Ureteral injuries from penetrating trauma, J Trauma 36:766, 1994.

30. IMAGING FOR URETERAL INJURIES
Most injuries diagnosed during laparotomy and no imaging ever done
Contrast CT with delayed imaging—most common findings are extravasation of contrast into medial perirenal space and absence of contrast in distal ureter if transected
Retrograde pyelogram
IVP—one shot IVP done in OR for penetrating trauma

31. Delayed CT images showing extravasation of urine from ureteral injury

32. Blunt trauma
Penetrating trauma
Gross hematuria, or microhematuria with deceleration or hypotension or associated injuries
Stable, to CT + contrast + delayed films
Unstable, to OR
Gross or micro-hematuria
Unstable, to OR
Yes No
Potential ureteral injury (ureteral nonopacification or extravasation)
Abnormal
Intraoperative
One-shot IVP
Normal
Intraoperative one-shot IVP
Normal
Consider other sources for
hematuria (bladder, urethra, kidney)
Stent removal
6 weeks
After stent removal consider periodic renogram or surveillance ultrasound (defect hydronephrosis to rule out recurrence
Explore ureter and repair
Bullet/knife wound in vicinity of ureter

33. I Hematoma Contusion or hematoma without devascularization
American Association for the Surgery of Trauma (AAST) Ureter Injury Severity Scale Grade Description
I Hematoma Contusion or hematoma without devascularization
II Laceration <50% transection
III Laceration >50% transection
IV Laceration Complete transection with <2 cm devascularization
V Laceration Avulsion with >2 cm devascularization

34. MANAGEMENT OF URETERAL INJURIES
Treatment
Stents—Grade 1
Surgery—Grade 2 and above
Complications
Ureteral stricture
Fistula
Retroperitoneal fibrosis
Abscess/Sepsis

35. Intraoperative recognition
Minor ureteral injury
Major ureteral injury
Stent
Primary stented ureterourostony, psoas hitch, or flap with or without kidney mobilization
Consider placement of percutaneous nephrostomy in rare case of extremely long injury
Ureteral stent 6 weeks
Follow-up retrograde pyelography and stent removal or replacement as needed
Consider endoscopic methods (laser, balloon)
Primary stented ureteroureterostomy
After stent removal consider periodic renogram or surveillance ultrasound to rule our recurrence

36. Postoperative recognition
CT with contrast (+ delayed films) + retrograde pyelography
Minor ureteral injury
Major ureteral injury
Ureteral stent 6 weeks
Attempted retrograde stent placement
Follow-up retrograde pyelography and stent removal or replacement as needed
Fail
Success
Success
Percutaneous nephrostomy and anterograde stent placement, if possible
Consider endoscopic methods (laser, balloon)
Primary stented ureteroureterostomy, psoas hitch or flap
Consider autotransplant or ileal loop in rare case of extremely long injury
After stent removal consider renogram or surveillance ultrasound to rule out recurrence
Fail, wait
6 weeks

37. Case

39. Urinary Bladder Trauma
Mechanisms of Injury
Blunt—up to 85% of cases
70-95% of patients with bladder injuries will have pelvic fractures
6-10% of patients with pelvic fractures will have bladder injuries
Penetrating—up to 15% of cases
Surgical/Cystoscopy

40. Urinary Bladder Anatomy
Empty bladder is a pelvic organ and protected by pelvic bones
With distention, becomes an abdominal organ and more prone to injury due to direct trauma
Peritoneum covers superior surface of bladder

41. When are you concerned about a bladder injury?
Clinical Presentation
Suprapubic pain
Difficulty voiding
Gross Hematuria—incidence approaches 100%
Microscopic Hematuria possible with penetrating trauma, spontaneous bladder rupture
X-ray
Widened symphysis pubis is stongest predictor
Pelvic, sacrum, iliac, ramus fractures
Widening of SI joint

42. Diagnostic Studies Retrograde cystogram Retrograde CT cystogram
Either one follows urethogram if concern for urethral injury exists

43. Indications for Cystography
Blunt Trauma in close proximity to bladder with gross hematuria
Pelvic fractures from blunt mechanism with any degree of hematuria
Penetrating Trauma in proximity to the bladder
Penetrating trauma with any degree of hematuria

44. Technique for Cystogram
Retrograde urethrogram if indicated
Urinary catheter
100 cc contrast
Plain film
cc contrast (5cc/kg)
Empty bladder
Sensitivity for bladder rupture near 100% if each step performed

45. Retrograde Cystogram--Normal

46. Retrograde Cystogram—Post-Void, Normal

47. CT Cystogram
Same technique as for plain cystogram, no need to do post void study
Sensitivity also approaches 100%

48. Extraperitoneal Bladder Rupture
50-90% of bladder ruptures
Usually associated with pelvic fracture
Usually treated with urethral/suprapubic catheter

49. Retrograde Cystogram—Extraperitoneal Rupture

50. Retrograde Cystogram—Extraperitoneal Rupture

51. CT Cystogram—Extraperitoneal Rupture

52. CT Cystogram with Extraperitoneal Rupture

53. CT Cystogram with Extraperitoneal Rupture with Sagittal View

54. Intraperitoneal Bladder Rupture
15-35% of bladder ruptures
Bladder usually distended at time of trauma
Historically treated surgically
Conservative management possible

55. Retrograde Cystogram—Intraperitoneal Rupture

56. Retrograde Cystogram—Intraperitoneal Rupture

57. Retrograde Cystogram—Intraperitoneal Rupture

58. Retrograde Cystogram—Intraperitoneal Rupture

59. CT Cystogram-Intraperitoneal Rupture

60. CT Cystogram—Intraperitoneal Rupture

61. American Association for the Surgery of Trauma (AAST) Bladder Injury Severity Scale Grade Description
I Hematoma Contusion, intramural hematoma Laceration Partial thickness
II Laceration Extraperitoneal bladder wall laceration <2 cm
III Laceration Extraperitoneal (>2 cm) or intraperitoneal (<2 cm)
bladder wall laceration
IV Laceration Intraperitoneal bladder wall laceration >2 cm
V Laceration Intraperitoneal or extraperitoneal bladder wall laceration extending into the bladder neck or ureteral
orifice (trigone)

62. Urinary Bladder Ruptures
Patients may have both intra- and extra-peritoneal bladder ruptures
20-40% Mortality for
Associated Injuries
Hemorrhage
Sepsis

63. Case 22 year old male engaging in sexual activity
Hears and feels snap, crack and pop
No more sex
Diagnosis?

64. Penile Fracture

65. Urethral Injuries 10% of all injuries to GU system
Potentially most debilitating GU injury due to complications
Rare in women
Mechanism of Injury
Blunt trauma such as mvc, bike accidents, straddle mechanisms
Often associated with pelvic fractures
Rarely penetrating trauma
Occasionally iatrogenic

66. Urethral Anatomy Anatomy based on relation to urogenital diaphragm
Posterior
Prostatic
Membranous
Anterior
Bulbous
Penile

67. Posterior Urethral Injuries
80-90% occur in combination with pelvic fracture
10-25% of pelvic ring fractures disrupt posterior urethra as puboprostatic ligaments are torn or stretched
Associated with bladder injuries and vaginal lacerations

68. Anterior Urethral Disruption
Usually due to direct blunt force trauma such as saddle injury
Does not cause high riding prostate as injury is below the urogenital diaphragm
Ureteral injury present in 10-38% of penile fractures (rupture of one or both tunica albuginea, fibrous covering of corpus cavernosa)

69. When do you worry about urethral injuries?
Symptoms
Abdominal/Perineal Pain
Difficulty urinating—females can present with incontinence
Posterior—unable to urinate
Anterior—dysuria, small amounts
Signs
Gross hematuria
Blood at urethral meatus
Perineal swelling/ecchymosis
Vaginal lacerations
Inability to pass urinary catheter (gentle attempt)
Abnormal prostate exam
Absent
High riding
Boggy
X rays
Pelvic Fractures

70. Retrograde Urethrogram
If urethral injury suspected, you may try one gentle attempt at passing urinary catheter—if it does not pass easily, don’t push
Perform urethrogram—instill cc of contrast retrograde through urethra
Complete disruption—contrast extravasates and none reaches bladder
Partial disruption—contrast extravasates and some reaches bladder

71. Grade* Injury Type Description
American Association for the Surgery of Trauma (AAST) Urethra Injury Severity Scale
Grade* Injury Type Description
I Contusion Blood at urethral meatus; urethrography normal
II Stretch Injury Elongation of urethra without extravasation on urethrography
III Partial Extravasation of urethrography contrast at injury site with Disruption contrast visualized in the bladder
IV Complete Extravasation of urethrography contrast at injury site Disruption without contrast visualization in the bladder; <2 cm
of urethral separation
V Complete Complete transection with >2 cm urethral separation, or Disruption extension into the prostate or vagina

72. Normal Urethrogram

73. Grade III-Partial Urethral Disruption

74. Grade III Partial Urethral Disruption

75. Grade IV or V Complete Urethral Disruption

76. Grade V Complete Urethral Disruption

77. Urethral Trauma Diagnosis Treatment Complications
Retrograde Urethrogram
Treatment
Catheter, Stent, Primary anastomosis
Complications
Stricture
Impotence
Incontinence

78. Case

79. Testicular Trauma Mechanism—fall, kick, sports
Symptoms—pain, N/V, lightheaded, remorse
Diagnosis—laceration, contusion, fracture, dislocation

80. Testicular Trauma Diagnosis—Color flow Doppler ultrasound Management
Contusion—rest, ice, analgesia, F/U
Laceration, dislocation, rupture--operative

85. Penile Amputation

86. Penile Amputation

87. Penile Resurrection!