Review of Urological Trauma Guidelines

Review
Urological Trauma
Kusuma Chinaroonchai, M.D.
19 Nov 2015

Reference
• Micheal Coburn . Genitourinary Trauma. in: K.L Mattox, D.V Feliciano, E.E
Moore ( Eds.) Trauma. 4th edition. McGraw-Hill Companies, New York;
2012:1583–1602.
• Holevar M, Ebert J, Luchette F, et al. Practical Management Guidelines for The
Management of Genitourinary Trauma. The EAST Practice Management
Guidelines Work Group. 2004.
• Morey AF, Brandes S, Dugi DD 3rd et al. Urotrauma: AUA guideline. J Urol
2014; 192: 327–35
• Summerton DJ, Djakovic N, Kitrey ND et al. Guidelines on Urological Trauma,
March 2015. Available at: http://uroweb.org/guideline/urologicaltrauma/.
Accessed November 2015
• Bryk DJ, Zhao LC. Guideline of guidelines: a review of urological trauma
guidelines. BJU Int. 2015.
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Level of Evidence
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Incidence
• KL Mattox. Trauma 4th edition. 2012
• 2-5% of all trauma patients
• 10% of abdominal trauma patients
• AUA guideline. 2014
• 1-5% of all trauma patients
• 4.9 injuries/100,000 population in the U.S.
• Kidney injury is most common
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Incidence
• EAU guideline. 2015
• Kidney most genitourinary system injuried organ, Ureteral
trauma is rare.
• 5% of all trauma patients
• 10% of abdominal trauma patients
• Traumatic bladder injury mostly due to blunt injury
• Anterior urethra is most common by blunt or “fall-astride”
• Posterior urethra is usually injured in pelvic fracture cases
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Classification: AAST
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Classification:AAST
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Renal Trauma
• Epidemiology, aetiology and pathophysiology:
• 1-5% trauma cases
• Most common injury in genitourinary organ
• Male > female (3:1)
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EAU 2015

Renal Trauma
• 75% age < 44 yrs
• Related with male
• 1.3-5% of blunt mechanism injury
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AUA 2014

Renal Trauma
• 82-95% blunt mechanism & ~70% MVC
(AUA 2014)
• > 80% blunt mechanism (BJU
international 2015)
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Renal Trauma
• Hx & PE:
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EAU 2015

• 9% no haematuria in stab wounds and renal injury.
• 3-10% false negative in urine dipstick for haematuria.
Renal Trauma
• Lab investigation:
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EAU 2015

Renal Trauma
• Lab investigation:
• UPJ and renal pedicle injuries
• 80-94% have haematuria (BJU international 2015)
• 20-25% no haematuria (AUA 2014)
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• Microscopic haematuria does not warrant imaging. (Grade
B, AUA 2014)

Renal Trauma
• Investigation:
• CT whole abdomen + IV contrast
• Standard; Grade B
• Stable patient + gross hematuria
• SBP < 90 mmHg + microscopic hematuria
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AUA 2014

Renal Trauma
• Investigation:
• CT whole abdomen + IV contrast
• Recommendation; Grade C for Stable patient + concerning Hx or PE
• Rapid deceleration
• Significant blow to flank
• Lower rib fracture
• Significant flank ecchymosis
• Penetrating injury of abdomen, flank, or lower chest
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AUA 2014

Renal Trauma
• Investigation:
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EAU AUA
B
C

Renal Trauma
• Investigation:
• USG as FAST; sensitivity 48%
• Contrast enhanced USG; sensitivity 69%
• CT + IV contrast; sensitivity > 90%
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EAU 2015
• CT + IV contrast

Renal Trauma
• Investigation:
• Intravenous pyelography (IVP)
• Recommended only when it is the only
modality available.
• Sensitivity > 92%
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EAU 2015

Renal Trauma
• Investigation:
• One-shot intravenous pyelography (IVP)
• Rearly used
• Careful intraoperative palpation of the kidneys is
enough.
• Used when suspected single kidney (abnormal
size and consistency of contralateral kidney)
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Trauma, Mattox 7th ed

Renal Trauma
• Investigation:
• One-shot intravenous pyelography (IVP) before
retroperitoneal exploration in unstable patient:
• Recommendation; Grade C
• Exclude life-threatening renal injury
• Confirm the existence of a contralateral
functioning kidney
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AUA 2014

Renal Trauma
• One-shot intravenous pyelography (IVP)
technique:
• A bolus intravenous injection of 2 mL/kg of
radiographic contrast
• A single plain film taken after 10 minutes
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Trauma, Mattox 7th ed, AUA 2014, EAU 2015

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AUA 2014
Renal Trauma: Grading
• Grade I, II >> Low grade
• Grade > II >> High grade
Trauma, Mattox 7th ed
• Grade III, IV, V subgroup
Low risk : a
High risk: b
-Perirenal hematoma rim
distance > 3.5 cm
-Active intravascular contrast
extravasation
-A medial renal laceration site

• Conservative Rx
• Bed rest
• Serial Hct
• Repeat CT???
• Angioembolization
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Renal Trauma
Modalities of Rx
• Surgical exploration
• Renorrhaphy
• Partial nephrectomy
>> non vital fragment
• Nephrectomy
• Repaired
renovascular injury

Renal Trauma
Conservative Mx
• AUA 2014:
• Clinicians should use non-invasive
management strategies in
hemodynamically stable patients
with renal injury. (Standard;
Evidence Strength: Grade B
• The surgical team must perform
immediate intervention (surgery or
angioembolization in selected
situations) in hemodynamically
unstable patients with no or
transient response to resuscitation.
(Standard; Evidence Strength:
Grade B)
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• EAU 2015:
• Following blunt renal trauma,
stable patients should be
managed conservatively with
close monitoring of vital signs.
Grade B)
• Isolated grade 1-3 stab and
low-velocity gunshot wounds in
stable patients, after complete
staging, should be managed
expectantly. (Standard;
Evidence Strength: Grade B)
Conservative Rx in stable patients

Renal Trauma
Conservative Mx
• AUA 2014:
• Grade 1,2 and 3 (injuries
without hemodynamic
instability or devitalized
fragments) >>no need repeat
CT
• Grade 3 with hemodynamic
instability or devitalised
fragments, 4 and 5 >> repeat
CT at 36-72 hrs
(Recommendation; Evidence
Strength: Grade C)
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• EAU 2015:
• Grade 1-4 asymptomatic >>
no need repeat CT
• Grade 4b and 5 >> repeat CT
at 48-72 hrs
• Symptomatic cases of fever,
flank pain, or falling
haematocrit >> urgent repeat
CT
Grade B)

Renal Trauma
Angioembolization
• AUA 2014:
• It should be the initial
treatment for patients
with persistent bleeding
lesions as:
• Grades 3 & 4
lacerations
• Arteriovenous fistula
• Pseudoaneurysmwith persistent bleeding
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• EAU 2015:
• It’s indicated in patients with
active bleeding from renal
injury, but without other
indications for immediate
abdominal operation.
(Standard; Evidence
Strength: Grade B)
• It’s the first-line option in the
absence of other indications
for immediate open surgery.
and vascular fistulae

Renal Trauma
Angioembolization
• AUA 2014:
• It should be the initial
treatment for patients with
persistent bleeding lesions
as:
• Grades 3 & 4 lacerations
with active extravasation
• Arteriovenous fistula
• Pseudoaneurysm
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• EAU 2015:
• Main indications
• Active haemorrhage
• Pseudoaneurysm
• Vascular fistulae

Renal Trauma
Operative indication
• AUA 2014:
• Absolute indication:
• Life threatening
hemorrhage believed to
be from renal injury
• Renal pedicle avulsion
• Expanding, pulsatile or
uncontained
retroperitoneal hematoma
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• EAU 2015:
• Indications for renal exploration:
• Haemodynamic instability
• Exploration for associated
injuries
• Expanding or pulsatile peri-renal
haematoma identified during
laparotomy
• Grade 5 vascular injury
Grade B)

Renal Trauma
Operative indication
• AUA 2014:
• Relative indication:
• Incomplete radiographic
staging with concurrent
traumatic injuries that
require repair/exploration
• extensive devitalized
renal parenchyma,
vascular injury and
urinary extravasation.
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• EAU 2015:
• Indications for renal exploration:
• Haemodynamic instability
• Exploration for associated
injuries
• Expanding or pulsatile peri-renal
haematoma identified during
laparotomy
• Grade 5 vascular injury
Grade B)

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Renal Trauma Mx: AUA
2014

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Renal Trauma Mx: EAU
2015
Blunt Injury

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Renal Trauma Mx: EAU
2015
Penetrating Injury

Renovascular Injury
• AUA and EAU:
• Conservative Rx
• Angioembolization in unstable cases
• Repaired in solitary kidney or bilateral injury
• Explor for other injuries situation
• Repaired in early warm ischemic time (20-30 mins)
• Nephrectomy in hilar injury with prolonged warm ischemic
time
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• Renal reconstruction should be attempted once
haemorrhage is controlled (Grade B, EAU).
• The benefit of prior vascular control is
inconclusive (Grade B, AUA).
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Operative Renal Trauma
Mx

• Renorrhaphy is most common operation.
• Nephrectomy in exploration only 13%.
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Operative Renal Trauma
Mx
EAU 2015

Renal Trauma
Follow up
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EAU 2015

Renal Trauma
Complication
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• AUA 2014:
• Urinary drainage in the presence
of complications such as
enlarging urinoma, fever,
increasing pain, ileus, fistula or
infection. (Recommendation;
Evidence Strength: Grade C)
• Ureteral stent drainage should
be achieved and may be
augmented by percutaneous
urinoma drain, percutaneous
nephrostomy or both. (Expert
Opinion)
• EAU 2015:
• Persistent urinary extravasation from
an otherwise viable kidney after blunt
trauma often responds to stent
placement and/or percutaneous
drainage as necessary.
• Delayed retroperitoneal bleeding may
be life-threatening and selective
angiographic embolisation is the
preferred treatment.
• Perinephric abscess formation is best
managed by percutaneous drainage,
although open drainage may
sometimes be required.

Ureteral Trauma
• 1-2.5% of urinary trauma cases
• 2-3% GSW abdominal injury
• Most common injury in upper ureter (deceleration mechanism)
• Blunt injury related with severe abdominal and pelvic injuries.
• Penetrating injury related with vascular and intestinal injuries.
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AUA 2014, EAU 2015

Ureteral Trauma
Diagnosis
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• AUA 2014:
• High index of suspicious.
• Clinicians should perform IV contrast
enhanced abdominal/pelvic CT with
delayed imaging (urogram) for stable
trauma patients with suspected
ureteral injuries. (Recommendation;
• Clinicians should directly inspect the
ureters during laparotomy in patients
with suspected ureteral injury who
have not had preoperative imaging.
(Clinical Principle)
• EAU 2015:
• High index of suspicious.
• Extravasation of contrast medium
in computerised tomography (CT)
is the hallmark sign of ureteral
trauma.
• In unclear cases,a retrograde or
antegrade urography >> gold
standard for confirmation.
• IVP esp. one-shot IVP >>
unreliable in diagnosis (false
negative rate 60%).

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Ureteral Trauma: Grading
*Advance one grade for bilateral up to grade III.
AAST grading

Ureteral Trauma
Management
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• AUA 2014:
• Repair traumatic ureteral lacerations
at the time of laparotomy in stable
patients. (Recommendation;
• Temporary urinary drainage followed
by delayed definitive management of
ureteral injuries in unstable patients
• Manage traumatic ureteral contusions
at the time of laparotomy with ureteral
stenting or resection and primary
repair depending on ureteral viability
and clinical scenario. (Expert
Opinion)
• EAU 2015:
• Immediate repair of ureteral injury
is usually advisable in stable
patients.
• Unstable trauma patients, a
‘damage control’ approach is
preferred with ligation of the ureter,
diversion of the urine (e.g. by a
nephrostomy), and a delayed
definitive repair.
• Perinephric abscess formation is
best managed by percutaneous
drainage, although open drainage
may sometimes be required.
Stable >> repaired
Unstable >> Damage control with
temporary urinary diversion

Ureteral Trauma
Reconstructive Option
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• AUA 2014: (Recommendation; Evidence Strength:
Grade C)
• Ureteral injuries located distal
to the iliac vessels
• Ureteral reimplantation
• Primary repair over a
ureteral stent, when
possible.
• Ureteral injuries located
proximal to the iliac vessels
• Primary repair over a
ureteral stent, when
possible.

Ureteral Trauma
Reconstructive Option
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EAU 2015

Bladder Trauma
• Most common blunt injury. (mostly motor vehicle
accident)
• 60-90% associated with pelvic fracture. (but only 3.6% in
pelvic fracture cases)
• 44% have at least one other intra-abdominal injury
• Extraperitoneal > intraperitoneal > combined
• 4.1-15% combined with urethral injury
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EAU 2015

• 60% extraperitoneal type
• 30% intraperitoneal type
• 10% combined type
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BJU 2015
Bladder Trauma: Grading

Bladder Trauma
Diagnosis
• 77-100% haematuria (AUA 2014), Cardinal sign of bladder injury
(EAU 2015)
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• AUA 2014:
• Perform retrograde cystography (plain
film or CT) in stable patients with
gross hematuria and pelvic fracture.
(Standard; Evidence Strength: Grade
B)
• Perform retrograde cystography in
stable patients with gross hematuria
and a mechanism concerning for
bladder injury, or in those with pelvic
ring fractures and clinical indicators of
bladder rupture. (Recommendation;
Evidence Strength: Grade C)with persistent bleeding
• EAU 2015:
• Cystography is the preferred
diagnostic modality for non-
iatrogenic bladder injuries, and in
suspected,iatrogenic, post-
operative, bladder injuries.
Grade B)
• Cystography (conventional or CT
imaging) is required in the
presence of visible haematuria
and pelvic fracture. (Standard;
• Retrograde Cystography is best modality for Dx
(Sent 90-95%, Spec 100%)
• Used in hematuria with clinical suspected injury as
pelvic fracture

• Cystography must be performed using retrograde filling of the
bladder with a minimum volume of 350 mL of dilute contrast
material.
• Intraperitoneal bladder injury:
• Intraperitoneal extravasation
• Free contrast medium is visualised in the abdomen, highlighting
bowel loops and/or outlining abdominal viscera such as the
liver.
• Extraperitoneal bladder injury: flame-shaped areas of contrast
extravasation in the perivesical soft tissues
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Retrograde Cystography
EAU 2015

Bladder Trauma
Treatment
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• Surgical exploration and repair
• Surgeons must perform surgical
repair of intraperitoneal bladder
rupture in the setting of blunt or
penetrating external trauma. (AUA
2014, Standard; Evidence
Strength: Grade B)
• Intraperitoneal bladder ruptures by
blunt trauma, and any type of
bladder injury by penetrating
trauma, must be managed by
emergency surgical exploration
and repair. (EAU 2015, Standard;
• Conservative treatment
• Clinicians should perform
catheter drainage as treatment
for patients with uncomplicated
extraperitoneal bladder
injuries. (AUA 2014,
Recommendation; Evidence
Strength: Grade C)
Intrapertioneal
bladder injury
in any mechanism

Bladder Trauma
Treatment
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• Surgical exploration and repair
• Surgeons should perform surgical
repair in patients with complicated
extraperitoneal bladder injury.
(AUA 2014, Recommendation;
• Complicated:
• Bladder neck involvement
• Bone fragments in the bladder
wall
• Concomitant rectal injury or
entrapment of the bladder wall
• Conservative treatment
• Clinicians should perform catheter
drainage as treatment for patients
with uncomplicated extraperitoneal
bladder injuries. (AUA 2014,
Recommendation; Evidence
Strength: Grade C)
• In the absence of bladder neck
involvement and/or associated
injuries that require surgical
intervention, extraperitoneal bladder
ruptures caused by blunt trauma
are managed conservative. (EAU
2015, Standard; Evidence Strength:
Grade B)

Sx Technique
Bladder Injury
• Two-layer vesicorraphy (mucosa-detrusor) with
absorbable sutures. (EAU 2015)
• Clinicians should perform urethral catheter
drainage without suprapubic (SP) cystostomy in
patients following surgical repair of bladder
injuries. (AUA 2014, Standard; Evidence Strength:
Grade B)
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Bladder Trauma
Follow Up
• Conservative Rx
• Planned 1st cystography at 7-14 day post injury.
• Operative repair
• Simple injury: removed cath in 7-10 days without a
cystography
• Complex injury (trigone involvement, ureteric
reimplantation) or in the case of risk factors of wound
healing >> control cystography
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&
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EAU 2015

Urethral Trauma
• Rare in female
• In male classify into anterior & posterior urethral
injury
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&
B
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N
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EAU 2015

Urethral Injury
• Mechanism
• Blunt
• Penetrating
• Location
• Anterior urethral injury
• Posterior urethral injury
• Lesion
• Partial rupture
• Complete rupture
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A
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&
B
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N
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Urethral Trauma
• Anterior urethral injury:
• Most blunt mechanism (‘straddle injuries’ or
kicks in the perineum)
• Bulba urethra most common
T
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A
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&
B
U
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N
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N
I
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EAU 2015

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EAU 2015
Anterior Urethral
Trauma

Urethral Trauma
• Posterior urethral injury:
• 72% related with pelvic fracture
• Classify into partial VS complete rupture
• Risk of urethral injury in type of pelvic fracture
• Straddle fractures with a concomitant diastasis
of the sacroiliac joint > straddle fractures alone
> Malgaigne fractures
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EAU 2015

Type Pelvic Fx
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• Straddle fractures
with a concomitant
diastasis of the
sacroiliac joint
• Malgaigne fractures

Urethral Trauma
• Posterior urethral injury:
• 45% found erectile dysfunction (ED) with strong predictors
factor
• Diastasis of the pubic symphysis
• Lateral displacement of the prostate
• A long urethral gap (> 2 cm)
• A bilateral pubic rami fracture
• A Malgaigne’s fracture
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EAU 2015

Urethral Trauma
Diagnosis
• Signs:
• Blood at meatus >> cardinal sign
• Inability to void >> suspected complete rupture
• ***Rectal exam*** >> 5% associated rectal injury in male (EUA
2015)
• ‘High riding’ prostate >> unreliable finding
• ***Vaginal exam*** >> associated vaginal injury in female
• Difficulty or inability to pass urethral catheter
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Grade C, AUA 2014

• EAU 2015:
• Retrograde urethrography is
the gold standard for evaluating
urethral injuries. (Standard;
Urethral Trauma
Investigation for Diagnosis
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&
B
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• AUA 2014:
• Clinicians should perform
retrograde urethrography in
patients with blood at the
urethral meatus after pelvic
trauma. (Recommendation;
Retrograde urethrography
is
investigation of choice

Penetrating
Anterior Urethral Injury
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N
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• AUA 2014:
• Surgeons should perform
prompt surgical repair in
patients with uncomplicated
penetrating trauma of the
anterior urethra. (Expert
Opinion)
• EAU 2015:
• Immediate exploration is
advised, except when this is
precluded by other life-
threatening injuries.

Blunt
Anterior Urethral Injury
T
R
A
U
M
A
&
B
U
R
N
U
N
I
T
• AUA 2014:
• Clinicians should establish
prompt urinary drainage in
patients with straddle injury to
the anterior urethra.
Strength: Grade C)
• EAU 2015:
• Blunt anterior urethral injuries
should be treated by
suprapubic diversion.
Strength: Grade C)

Penetrating
Posterior Urethral Injury
• Management dependent on
• Associated injuries:
With VS without rectal injury
• Clinical condition of the patient:
stable VS unstable
T
R
A
U
M
A
&
B
U
R
N
U
N
I
T
EAU 2015

Penetrating
T
R
A
U
M
A
&
B
U
R
N
U
N
I
T
EAU 2015
• Clinical:
• Unstable >> suprapubic
diversion with delayed
abdominoperineal urethroplasty
• Stable >> immediate
exploration by the retropubic
route and primary repair or
realignment
• Rectal injury:
• With rectal injury >> Diverting
colostomy

Blunt
T
R
A
U
M
A
&
B
U
R
N
U
N
I
T
EAU 2015
• Immediate urinary diversion
consider :
• To monitor urinary output
(haemodynamic condition and
the renal function)
• To treat symptomatic retention
(conscious patient)
• To minimise urinary
extravasation (its secondary
effects, such as infection and
fibrosis)
• Urinary diversion:
• Suprapubic catheter should be
placed under US guidance
and direct vision.

Blunt
• Clinicians should establish prompt urinary drainage in patients with
pelvic fracture associated urethral injury. (Recommendation; Evidence
Strength: Grade C)
• Surgeons may place suprapubic tubes (SPTs) in patients undergoing
open reduction internal fixation (ORIF) for pelvic fracture. (Expert
Opinion)
• Clinicians may perform primary realignment (PR) in hemodynamically
stable patients with pelvic fracture associated urethral injury. (Option;
• Clinicians should not perform prolonged attempts at endoscopic
realignment in patients with pelvic fracture associated urethral injury.
T
R
A
U
M
A
&
B
U
R
N
U
N
I
T
AUA 2014

Blunt Partial
T
R
A
U
M
A
&
B
U
R
N
U
N
I
T
EAU 2015
• Follow up:
• 2 wks urethrography
• Complication:
• Residual or subsequent
stricture
• Internal urethrotomy: short
and non-obliterative
• Anastomotic urethroplasty:
long and dense, complete
obliteration, failed internal
urethrotomy

Blunt Complete
T
R
A
U
M
A
&
B
U
R
N
U
N
I
T
EAU 2015
• Standard treatment:
• Deferred treatment
• 3 mths suprapubic diversion
• Deferred urethroplasty at a
minimum 3 mths after : a
one-stage perineal approach
• Surgical > endoscopic
• Alternative treatment: ***Need
experienced hand***
• Acute definitive treatment (<48
hrs after injury)
• Delayed primary treatment (2
days - 2 wks after injury)

Blunt Complete
Alternative treatment
• Delayed primary treatment
(2 days - 2 wks after injury)
• Immediate realignment:
apposition of the urethral
ends over a catheter
(endoscopic method)
• Immediate urethroplasty:
suturing of urethral ends
• Not affect rate of
subsequent stricture
T
R
A
U
M
A
&
B
U
R
N
U
N
I
T
• Benefits:
• Lower stricture rate
• Simplified scarring and subsequent
stricture
• Easier future uretheroplasty
• Bleeding better resolved
• Limitation:
• Stable
• Short defect
• Enable lithotomy position

Blunt Complete
Alternative treatment
• Acute definitive treatment
(<48 hrs after injury)
• Associated with bladder
neck or rectal injury
• Immediate realignment:
apposition of the urethral
ends over a catheter
(endoscopic method)
• Immediate urethroplasty:
suturing of urethral ends
T
R
A
U
M
A
&
B
U
R
N
U
N
I
T
• Benefits:
• Lower stricture rate
• Simplified scarring and
subsequent stricture
• Easier future uretheroplasty
• Risks:
• Uncontrolled bleeding
• Extensive unjustified tissue
debridement

Urethral Injury
Follow Up
• Clinicians should monitor patients for
complications (e.g., stricture formation, erectile
dysfunction, incontinence) for at least one year
following urethral injury. (Recommendation;
T
R
A
U
M
A
&
B
U
R
N
U
N
I
T
AUA 2014

T
R
A
U
M
A
&
B
U
R
N
U
N
I
T

Summary
• Kidney:
• CT + IV contrast
• Mostly conservative Rx
• Operative Mx as indicated (mostly renorrhaphy)
T
R
A
U
M
A
&
B
U
R
N
U
N
I
T

Summary
• Ureter:
• CT + IV contrast + Delayed phase (urogram)
• Stable patient >> repair
• Unstable patient >> demage control + diversion
• Lesion above iliac vessel >> repaired over stent
• Lesion below iliac vessel >> reimplant
T
R
A
U
M
A
&
B
U
R
N
U
N
I
T

Summary
• Bladder:
• Retrograde cystography
• Extraperitoneal type: mostly conservative Rx
• Intraperitoneal type: Surgical repair
T
R
A
U
M
A
&
B
U
R
N
U
N
I
T

Summary
• Urethra:
• Retrograde urethrography
• Penetrating urethral injury >> surgical repair
• Blunt anterior urethral injury >> Urinary drainage
(prefered SPC)
• Blunt posterior urethral injury
• Partial >> urinary drainage (Prefered SPC) 2 wks
• Complete >> deferred treatment (SPC 3mth +
deferred surgical urethroplasty)
T
R
A
U
M
A
&
B
U
R
N
U
N
I
T

Review of Urological Trauma Guidelines

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