1. Genitourinary Trauma
10th Jan, 2013
By : Ext. Sirada Chittiwan
Ext. Jaipisut Rattanakajornsak

2. Introduction
• 10-20% of all injured patients
• Kidney : The most common
• Life-threatening injuries first
A: airway with cervical spine protection
B: breathing
C: circulation and control of external bleeding
D: disability or neurological status
E: exposure (undress) and environment
(temperature control)

3. Content
• Upper Urinary tract trauma
 Renal injuries
 Ureteral injuries
• Lower Urinary tract trauma
 Bladder injuries
 Urethral injuries
• External Genitalia injuries

4. Upper
Urinary tract trauma

5. Renal Injuries

6. RENAL INJURIES : Etiology
• The most common of all injuries to the GU
system
• Blunt trauma 80-85%
– Motor vehicle accidents, fights, falls, contact sports
– Vehicle collision at high speed : rapid deceleration
, major vascular injury
• Penetrating : Associated abdominal visceral injuries 80%
- Gunshot wounds
- Stab wounds

7. Mechanism of Renal Injuries

8. Clinical findings
• Pain : localized to one flank area or over the
abdomen
• Gross or microscopic hematuria
• Ecchymosis in the flank or upper quadrants of
the abdomen
• Lower ribs or transverse process fracture
• Palpable mass : large retroperitoneal hematoma
or urinary extravasation
• Generalized peritonitis

9. American Association for Surgery of Trauma
Organ Injury Severity Scale for the Kidneys
Classification

11. Indications for Renal Imaging
• Blunt trauma with gross hematuria
• Blunt trauma with microscopic hematuria and
shock (SBP < 90 mmHg anytime)
• Penetrating injuries with any degree of hematuria
• Pediatric patients (< 16 years)
• suspected any possible renal injury (e.g. patients
sustaining blunt trauma from rapid deceleration )

12. Imaging studies
• Contrast-enhanced CT -- preferred
• Single-shot intraoperative excretory urography
• Arteriography
• Sonography

13. Imaging Studies : Contrast-Enhanced CT
The preferred imaging study;
• Parenchymal lacerations
• Extravasation of contrast-enhanced urine
• Associated injuries
• Degree of retroperitoneal bleeding
• Lack of uptake of contrast material in the
parenchyma suggests arterial injury

15. Findings on CT that suggest
Major injury
(1) medial hematoma : suggesting vascular injury
(2) medial urinary extravasation : suggesting renal
pelvis or ureteropelvic junction avulsion injury
(3) lack of contrast enhancement of the
parenchyma : suggesting arterial injury

16. Single-shot intraoperative IVP
• Only a single film is taken 10 minutes after
intravenous injection (IV push) of 2 mL/kg of
contrast material
• If findings are not normal or near normal, the kidney
should be explored to complete the staging of the
injury and reconstruct any abnormality found

17. Arteriography
• To define arterial injuries suspected on CT
• To localize arterial bleeding that can be controlled
by embolization

18. Sonography
• Immediate evaluation of injuries
• Confirms the presence of two kidneys
• Can easily define any retroperitoneal hematoma
• Cannot clearly delineate parenchymal lacerations
and vascular or collecting system injuries
• Cannot accurately detect urinary extravasation in
acute injuries

20. MANAGEMENT
• Nonoperative Management
• Operative Management

21. Nonoperative Management :
Isolated Renal Injuries
• Approximately 80% to 90% of renal injuries have
major associated organ injury
• Blunt trauma can be managed nonoperatively
• Patients with grade IV parenchymal lacerations can be
observed expectantly
• Complete bed rest
• IV fluid replacement
• ATB prophylaxis
• Analgesic and Sedation
•TT prophylaxis

22. Operative Management
• Absolute indications
– Evidence of persistent renal bleeding
– Expanding perirenal hematoma
– Pulsatile perirenal hematoma
• Relative indications
– Urinary extravasation
– Nonviable tissue
– Delayed diagnosis of arterial injury
– Segmental arterial injury
– Incomplete staging

23. Renal Exploration
Surgical exploration of the
acutely injured kidney is best done by
Transabdominal approach
allows complete inspection of
intra-abdominal organs and bowel

24. Surgical Approach to
the renal vessels and kidney

25. Renal Reconstruction

26. Technique for Renorrhaphy

27. Renovascular Injuries

29. Indications for Nephrectomy
• Unstable patient, with low body temperature and
poor coagulation
• Extensive renal injuries when the patient’s life
would be threatened by attempted renal repair

30. Complications
• Urinoma – internal ureteral stent
• Perinephric abscess – percutaneous
draingage, surgical drainage
• Delayed renal bleeding
– Usuall occurs within 21 days
– Angiography and embolization
• Hypertension

31. Arterial Hypertension
• Renal vascular injury, leading to stenosis or
occlusion of the main renal artery or one of its
branches
• Compression of the renal parenchymal with
extravasated blood or urine
• Post-trauma arteriovenous fistula

34. Ureteral Injuries

35. URETERAL INJURIES : Etiology
• External Trauma (20%)
- After external violence are rare (<1%)
- 10 - 28% have associated renal injuries
- 5% have associated bladder injuries
• Surgical Injury (80%)
– Pelvic surgical procedure (M/C: Hysterectomy)
– Endoscopic manipulation, etc.

37. Clinical findings
• Post operative fever
• Flank and lower quadrant pain
• Paralytic ileus with nausea and vomitting
• Peritonitis
• Uretervaginal fistula
• Ureterocutaneous fistula
• Hematuria

38. American Association for the Surgery of Trauma
Organ Injury Severity Scale for the Ureter

39. Imaging Studies
• Excretory Urography : intraoperative one-shot
pyelography
• Computed Tomography - IVP
• Retrograde Ureterography
• Antegrade Ureterography : If retrograde stent
placement is not possible

40. Imaging findings
• Excretory urography
– Delayed function
– Hydronephrosis
– Extravasation
• Retrograde
ureterography
– Demonstrates the exact
site of obstruction or
extravasation

41. Treatment
• Repair when injury occurs
– Before 7 days  immediate Reexploration and
repair
– Delayed diagnosis  nephrostomy + repair after
3 months
Goals of ureteral repair
– Complete debridement, tension-free spatulated
anastomosis, watertight closure, ureteral
stenting, retroperitoneal drainage