Upper Genitourinary Trauma

1. UPPER GENITOURINARY
TRAUMA
PREPARED BY DR MANIRABONA EMMANUEL, PG-Y2 GENERAL SURGERY
SUPERVISED BY DR NGENDAHAYO EDUARD, UROLOGY CONSULTANT

2. OUTLINE
I. INTRODUCTION
II. BRIEF ANATOMY
III. KIDNEY TRAUMA
IV. URETERIC TRAUMA
V. TAKE HOME MESSAGE
VI. REFERENCES

3. INTRODUCTION
• Genitourinary injuries account 10 % of all abdominal trauma
• Kidney account 84 %, bladder and urethra, 8% each one
• Early diagnosis is essential to prevent serious complications
• Initial assessment include control of hemorrhage and shock along with
resuscitation
• Urethral meatus should be examined presence of blood before catheterization

4. BRIEF ANATOMY
• Bean shaped highly vascular
organs whose primary
function to eliminate waste
products
• Left: protected by spleen,
chest wall, diaphragm,
pancreatic tail, descending
colon
• Right: lower than left due to
position of liver; protected
by diaphragm, liver,
duodenum

5. • The kidney is well protected by heavy
lumbar muscles, vertebral bodies,
ribs, and the viscera anteriorly
• Fractured ribs and transverse
vertebral processes may penetrate
the renal parenchyma or vasculature

6. URETERS
• They are narrow thick-walled expansile
muscle tube
• Conveys urine from kidneys to the
urinary bladder
• urine is propelled by peristaltic
contractions of the smooth muscles of
the wall of ureter
• Ureter measures 25cm length and 3mm
diameter

7. • Ureter is divided into 2 parts each measuring
12.5cm
• The abdominal part of ureter extends from
renal pelvis to the bifurcation of the
common iliac artery
• The pelvic part of the ureter extends from the
pelvic brim (at the level of bifurcation of the
common iliac artery) to the base of urinary
bladder.
• Ureter has 3 anatomical constrictions

8. RENAL TRAUMA
• Renal injuries occur in 1–5% of all trauma cases
• Renal trauma can be life-threatening
• Kidney is the most commonly injured genitourinary organ at all ages, with a male
: female ratio of 3:1
• Children are more susceptible to renal trauma than adults
• Renal trauma can be an isolated injury but in 80–95% of cases there are
concomitant injuries

9. RISK FACTORS
Preexisting renal abnormalities
1. Transplant kidney
2. Horseshoe kidney
3. Ectopic kidney
4. Renal tumor and cyst
5. Hydronephrosis
Pediatric kidney
Geriatric population

10. MECHANISM OF INJURY
• Blunt trauma accounts for 90-95% of renal injuries as result of RTA, falls, vehicle-
pedestrian accidents, contact sports and assault
• Gunshot and stab wounds represent the most common causes of penetrating
injuries
• Penetrating injuries tend to be more severe and less predictable and have
potential for greater parenchymal destruction and are most often associated with
other organ injuries

11. PATHOPHYSIOLOGY
• The kidney is covered by fat and Gerota’s fascia in the retroperitoneum with renal
pedicle and uretero-pelvic junction (UPJ) being their major attachment elements
• Deceleration forces on these attachment elements may cause renal injury like
rupture or thrombosis
• Acceleration forces may cause collision of the kidney in its surrounding elements,
like the ribs and spine, and cause parenchymal and vascular injury

12. GRADING OF RENAL INJURY
• The most common renal trauma classification is the American Association for the
Surgery of Trauma (AAST) classification
• The AAST grade is a predictor for morbidity in blunt and penetrating renal injury,
and for mortality in blunt injury
• Classifying renal injuries helps to select appropriate therapy and predict results.
• It is based on abdominal computed tomography (CT) or direct exploration and is
able to predict the need for intervention

14. INITIAL EVALUATION
• Kidney injury patient like any other one who consults for trauma follows ATLS
Protocols
• Primary Survey
• Secondary Survey
• Definitive Management

15. PATIENT HISTORY
• In penetrating injuries the size of the weapon in stabbings, caliber of weapon
used in GSW are noted
• PMH for pre-existing organ dysfunction and anatomical abnormality (e.g.,
hydrone- phrosis, calculi, cysts, tumors) makes injury more likely
• Shock is an indicator for severe trauma, vital signs have to be monitored
throughout diagnostic evaluation

16. PHYSICAL EXAMINATION
• Abdominal distention from
retroperitoneal bleeding and
hematuria
• Ecchymosis in the flank or upper
quadrants of the abdomen
• Lower rib fractures are frequently
found
• Diffuse abdominal tenderness “acute
abdomen” indicates free blood in the
peritoneal cavity.

17. • Palpable mass may represent a large
retroperitoneal hematoma or
perhaps urinary extravasation
• Obvious penetrating trauma from a
stab wound to the lower thoracic
back, flanks and upper abdomen, or
bullet entry or exit wounds

18. INVESTIGATIONS
• Urinalysis-hematuria is the first indicator for renal injury but it is neither sensitive
nor specific
• Urine dipstick is a reliable and rapid test
• Creatinine measurement reflects renal function prior to the injury

19. RADIOLOGICAL EVALUATION
• Goal of initial imaging is to grade the renal injury
• Demonstrate contralateral kidney and preexisting renal abnormalities
• Identify injuries to other organs
• Not all patients need renal imaging
• Microscopic hematuria and no shock after blunt trauma have a low likelihood of
significant injury

20. INDICATIONS FOR RADIOLOGY – CT SCAN
• Gross hematuria
• Microscopic hematuria and shock
• Presence of associated major injuries
• Any degree of hematuria following abdominal trauma in a child
• Patients with penetrating trauma to the torso regardless of the degree of
hematuria
• Abnormalities on initial ultrasound suspicious of renal trauma

21. ULTRASONOGRAPHY
• It detects peritoneal fluid collections and renal lacerations
• Identify which patients require further radiological investigation
• Useful for the follow-up of parenchymal lesions, hematomas and urinomas
• It cannot definitely assess the depth and extent of renal injury and does not
provide functional information about renal excretion or urine leakage

22. COMPUTED TOMOGRAPHY
• CT is the gold standard method for the radiographic assessment of renal trauma
in the stable patient
• It defines the location and depth of renal injuries
• Detects contusions and devitalized segments, visualizes the entire
retroperitoneum, abdomen and pelvis and associated hematomas and other
organ injuries.
• Evaluate traumatic injuries to kidneys with pre-existing abnormalities

23. • CT Scan with contrast should be administered for renal evaluation
• Lack of contrast enhancement of the injured kidney is a hallmark of renal pedicle
injury
• Central perihilar hematoma increases the possibility of pedicle injury even if the
parenchymal system is well enhanced
• Delayed or excretory scans 10-15 minutes after injection of contrast should be
obtained to determine injury to the collecting system

24. INTRAVENOUS PYELOGRAM (IVP)
• IVP is no longer the study of choice for the initial evaluation of renal trauma
• Used to establish the presence or absence of one or both of the kidneys
• define the renal parenchyma and outline the collecting system
• Non-visualization, contour deformity or extravasation of contrast implies a major
renal injury

25. ONE-SHOT INTRAOPERATIVE IVP
• Unstable patients selected for immediate operative intervention
• Technique consists of a bolus intravenous injection of 2 ml/kg of radiographic
contrast followed by a single plain film taken after 10min
• Provides information concerning the injured kidney, as well as the presence of a
normal functioning kidney on the contralateral side
• Limited value in patients with penetrating and associated abdominal injuries
particularly those undergoing laparotomy.

26. TREATMENT
• Patients with grade 1-3 can be treated non-operatively and this is the case in the
majority of patients with renal trauma
• In stable patients, supportive care with bed-rest, hydration and antibiotics is the
preferred initial approach
• Primary conservative management is associated with a lower rate of nephrectomy
without any increase in the immediate or long-term morbidity

27. OPERATIVE MANAGEMENT
• The overall renal exploration rate for blunt trauma is <10%
• The goal of renal exploration is to control hemorrhage and preserve renal tissue
• Renorrhaphy is the most common reconstructive technique.
• Nephrectomy is indicated in cases of uncontrolled blood loss, renal pedicle
injury and significantly devitalized renal tissue

28. INDICATIONS FOR RENAL EXPLORATION
Absolute Indications
• Life-threatening hemodynamic instability due to renal hemorrhage
• Expanding or pulsatile perirenal hematoma identified at exploratory laparotomy
• Poor visualization or any other abnormality of the injured kidney
• Renal vascular pedicle injuries (AATS grade 5)
• Urinoma unresponsive to ureteral stenting or perinephric drainage

29. Relative Indications
• Large laceration of the renal pelvis or avulsion of the PUJ
• Laparotomy for Co-existing abdominal injuries
• Devitalized parenchymal segment with urinary leak
Stable hematomas detected during exploration for associated injuries should
be opened
central or expanding hematomas indicate injury of the big vessels and require
immediate exploration with vascular expertise

30. FOLLOW UP AND COMPLICATIONS
Early complications include
Bleeding, Infection, Peri-nephric abscess, Sepsis, Urinary Fistula, Hypertension,
Urinary Extravasation And Urinoma
Delayed complications include
Hydronephrosis, Calculus Formation, Chronic Pyelonephritis, Hypertension,
Arteriovenous Fistula And Pseudoaneurysms

31. Risk of complications following conservative management increases with grade 3 -
5
Repeat imaging minimizes the risk of missed complications
Follow-up should involve
Physical Examination, Urinalysis, Radiologic Investigation, Serial Blood Pressure
and Serum creatine measurement

32. URETERIC INJURIES
• Trauma to the ureter is a relatively rare (1%) in urinary tract trauma
• Trauma to the ureters is rare because they are protected from injury by their small
size, mobility, and the adjacent vertebrae, bony pelvis, and muscles
• Ureter is at risk of injury when there is external injury to the flank, back or bony
pelvis

33. ETIOLOGIES
• Majority of ureteric injuries are iatrogenic (75%) mainly gynecological surgery
• Ureteric injury from blunt trauma occurs in 18 % cases
• Penetrating trauma mainly GSW injures ureter in 7%
• Distal ureter is mostly involved

34. DIAGNOSIS
• External ureteral trauma is rare and usually accompanies severe abdominal and
pelvic injuries and require high index of suspicion
• Diagnosis is commonly made intraoperatively during laparotomy for other injuries
• Hematuria is unreliable and present in only 50–75% of patients

35. Delayed Diagnosis
• Flank pain
• Urinary incontinence,
• Vaginal or drain urinary leakage,
• Hematuria, fever, uremia, or urinoma

36. RADIOLOGICAL DIAGNOSIS
• Extravasation of contrast medium on CT scans or in IVP is the hallmark sign of
ureteral trauma
AAST ureteral injuries classification
• Grade 1: Hematoma only
• Grade 2: Laceration < 50% of circumference
• Grade 3: Laceration > 50% of circumference
• Grade 4: Complete tear < 2 cm of devascularization
• Grade 5: Complete tear > 2 cm of devascularization

37. MANAGEMENT
• Treatment depends on the extent and the location of ureteral 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

39. TAKE HOME MESSAGE
• The kidneys are the most vulnerable genitourinary organ in trauma
• The most common mechanism for renal injury is blunt trauma
• The mainstay of renal trauma diagnosis is based on contrast-enhanced computed
tomography
• conservative management is the best approach in stable patients
• Ureteric injury relatively rare in genitourinary trauma

40. REFERENCES
1. Smith & Tanagho’s General Urology EIGHTEENTH EDITION
2. Therapeutic Advances in Urology, Tomer Erlich and Noam D. Kitrey
3. Review of the Current Management of Upper Urinary Tract Injuries, Efraim
Serafetinides ,Noam D. Kitrey b, Nenad Djakovic et al
4. Trauma to the genitourinary tract,
Thomas Watcyn-Jones, Sanjeev Pathak, Patrick Cutinha