1. Genitourinary Trauma
Prof. DR. Mohamed ShafikProf. DR. Mohamed Shafik
Urology Department – Alexandria University

2. • ~10% of E.R. trauma visits
• Often associated with multi-system trauma
• Subtle presentations, easily overlooked
• Diseased GU organs susceptible to injury
GU Trauma
Objectives

3. • ~10% of E.R. trauma visits
• Often associated with multi-system trauma
• Subtle presentations, easily overlooked
• Diseased GU organs susceptible to injury
GU Trauma
General Considerations

4. • Airway
• with C-spine protection
• Breathing
• Circulation
• control of external hemorrhage, 2 large bore IVs
• Disability
• assessment of neurologic status
• Exposure / Environment
• undress / temperature control
GU Trauma
Evaluation

5. • Most commonly injured GU organ
• Often in association with multi-system organ
injury
• Blunt >80%
• Penetrating <20%
Renal Trauma
General Considerations

6. • Most common form of renal trauma
• Types of injury
– Motor vehicle accidents
– Falls from heights
– Assaults
• Mechanisms of injury
– High velocity impact (contusion / hematoma / laceration)
– Deceleration injury (RA thrombosis / RV disruption /
avulsion of renal pedicle)
Renal Trauma
Blunt

7. • Uncommon form of renal trauma
• Types of injury
– Gunshot wounds
– Stab wounds
• Mechanisms of injury
– Direct shearing force through renal tissue
Renal Trauma
Penetrating

8. • Hematuria (gross or microscopic)
– Microscopic = 5 RBCs/HPF
– May be absent
• Shock (hypotension, tachycardia, oliguria)
• Flank bruising/mass
• Flank pain/tenderness
Renal Trauma
Presentation

9. • Penetrating injuries
• Blunt injuries in association with:
– Gross hematuria
– Microscopic hematuria and shock (SBP < 90)
– Microscopic hematuria in children
– Microscopic hematuria in patient with solitary kidney
– Absence of hematuria but high clinical index of suspicion
of renal injury based on Hx, Px and AXR
• Rapid deceleration injury
• Lower rib #
• Transverse process #
• Loss of psoas shadow
Renal Trauma
Indications for Imaging

10. Consider the need for both anatomic and functional information
• IVP - “Single-shot” intra-op
• U/S - Confirm 2 kidneys
• Angiography - Used for embolization
These modalities have a limited role and have been essentially
replaced by CT scan
Renal Trauma
Options for Imaging

11. • Provides valuable anatomic and functional information
• Provides the most definitive staging information
• Provides information on associated injuries
• Imaging modality of choice for renal trauma
Renal Trauma
CT Scan

12. • Urinary extravasation medial to kidney
– Suggests UPJ avulsion or renal pelvic injury
• Hematoma medial to kidney, displacing it laterally
– Suggests pedicle injury
• Lack of contrast enhancement of kidney
– Suggests arterial injury
Renal Trauma
CT Findings – Major Trauma

13. • Many classification systems available
• Recommend:
– American Association for the Surgery of Trauma (AAST)
Organ Injury Severity Scale
• Because:
– Most widely used
– In Campbell’s
Renal Trauma
Classification

14. AAST
Renal Trauma
Classification

15. Pediatric Renal Trauma
Considerations
• Occupies proportionately larger space
• Less perirenal and subcutaneous fat
• Renal capsule, Gerota’s fascia and perirenal fat less
developed (? less fixation)
• Vascular pedicle more susceptible to shearing forces
• Higher catecholamine output after trauma

16. Pediatric Renal Trauma
Controversies
• What is appropriate investigation of suspected
renal injuries?
• What is the significance of degree of hematuria?
• Does the rule of microscopic hematuria and shock
still fit?

17. Pediatric Renal Trauma
Summary
• Shock not a useful parameter
• Hematuria may not be present ~10%
• Not all children with blunt trauma need to be
evaluated but...
• High index of suspicion based on mechanism
• “Liberal” use of imaging studies

18. • Conservative management for:
– 90-98% of blunt renal trauma
– Up to 50% of penetrating renal trauma
• ABCs
• Admission
• Bedrest until gross hematuria clears
• Close clinical observation
– Serial vital signs, CBC
Renal Trauma
Non-operative Management

19. ABSOLUTE
• Persistent renal bleeding
with hemodynamic
instability
• Expanding perirenal
hematoma
• Pulsatile perirenal
hematoma
Renal Trauma
Indications for Surgical Exploration
RELATIVE
• Penetrating injuries
• Extensive urine
extravasation
• Grade 5 injury
– “Shattered kidney”
– Pedicle injury
• Non-viable tissue (>20%)
• Arterial injury (main or

20. • Transabdominal midline laparotomy
• Early control of renal vessels
• Exposure of kidney
– Open Gerota’s fascia
– Dissect kidney from surrounding hematoma
• Decision: repair of kidney vs. removal of kidney
Renal Trauma
Principles of Surgical Exploration

21. • Complete renal exposure
• Debridement of non-viable tissue
• Hemostasis
– Suture ligature
– Gelfoam, Surgicel
– Argon beam coagulation
• Water-tight closure of collecting system
Renal Trauma
Principles of Renal Reconstruction

22. Renal Trauma
Technique of Renal Reconstruction

23. • Early
– Hemorrhage, shock
– Urinoma
• Late
– Infection
– Loss of renal function
– Hypertension
• BP checks with family doctor
Renal Trauma
Complications

25. • Relatively uncommon
• Often in association with multi-system organ injury
• Significant mortality rate (10-20%)
• Have high index of suspicion of urethral disruption
injury
• Bladder more susceptible to injury when full
Bladder Trauma
General Considerations

26. • Blunt
• Penetrating
• Iatrogenic
• Spontaneous rupture
Bladder Trauma
Etiology

27. BLUNT
• Most common type of bladder injury
• Usually motor vehicle accidents
• 2/3 contusions, 1/3 ruptures
• Associated with pelvic #
– 10-25% of pelvic #’s have associated bladder injury
– 85-90% of bladder injuries have associated pelvic #
PENETRATING
• Less common
• Often associated with major organ injuries
Bladder Trauma
Etiology

28. IATROGENIC
• Open or laparoscopic pelvic surgery
– Gynecologic, vascular, urologic or general surgery
SPONTANEOUS RUPTURE
• Underlying pathology
– Cancer, obstruction, XRT, TB, sensory neurologic deficit
Bladder Trauma
Etiology

29. • Hematuria
– 95% blunt injuries have gross hematuria
• Inability to void
• Abdominal pain
• Abdominal bruising
• Pelvic mass
• Peritoneal signs
• Shock
Bladder Trauma
Presentation

30. • Cystogram
– AP films ± obliques
– Remember drainage films
• 10% of bladder ruptures detected on drainage films
• CT Cystogram
– Often more efficient since most patients need CT anyway
– Provides additional helpful information about other organs
Bladder Trauma
Imaging

31. • Grade 1: Hematoma (contusion, intramural hematoma)
Laceration (partial thickness)
• Grade 2: Laceration (extraperitoneal, <2cm)
• Grade 3: Laceration (extraperitoneal, ≥2cm)
Laceration (intraperitoneal, <2cm)
• Grade 4: Laceration (intraperitoneal, ≥2cm)
• Grade 5: Laceration (intra- or extraperitoneal, extending into bladder
neck, ureteral orifice, trigone)
Advance one grade for multiple injuries up to grade 3
Bladder Trauma
AAST Organ Injury Severity Scale

32. • Contusion
– Most common
– Often diagnosis of exclusion
• Laceration/rupture
– Extraperitoneal
vs. This is what we really need to know
– Intraperitoneal
Bladder Trauma
Practical Classification

33. GENERAL PRINCIPLES
• ABCs
• Establish urinary drainage/diversion
• Antibiotics
CONTUSION
– No specific therapy required
Bladder Trauma
Management

34. EXTRAPERITONEAL RUPTURE
• Conservative, catheter drainage x 7-14 days,
cystogram
• Indications for surgical repair:
– Patient already in O.R. for another reason
– Associated rectal perforation or open pelvic fracture
– Bone fragments projecting into bladder
– Multiple/large ruptures
Bladder Trauma
Management

35. INTRAPERITONEAL RUPTURE
• Surgical repair
– Midline laparotomy/cystotomy
– Multi-layer closure of bladder injury
– Bladder drainage
• Foley catheter ± suprapubic catheter
– Perivesical drain
Bladder Trauma
Management

36. • Intraperitoneal
– Urinary frequency
– Shock
– Peritonitis
– Azotemia
• Extraperitoneal
– Shock
– Pelvic abscess
Bladder Trauma
Complications

37. • 46 y/o woman undergoes TAH-BSO for severe
endometriosis
– Significant bleeding intra-op, requires 4 units pRBCs
• POD# 4:
– Still not able to tolerate solids
– C/o R flank pain
– T=38.6°C
• What would you do now?
Case #3

38. R kidney
L kidney

40. • External trauma very rare
– <4% of penetrating trauma
– <1% of blunt trauma
– Look for concomitant visceral injuries (SB, LB, K, B)
• Usually surgical trauma
– Gynecologic, vascular, urologic or general surgery
• Open
• Laparoscopic
– Ureteroscopy
Ureteral Trauma
Etiology

41. • At time of external trauma
• If unrecognized intra-op, then:
– Low grade fever, ileus
– Flank pain
– Fluid drainage from incision, drain sites
• Hematuria may be absent
Ureteral Trauma
Presentation

42. • Methylene blue
– IV or renal pelvic injection
– For suspected intra-op ureteral injury
– Allows localization of injury
• IVP
• CT scan
• Ureteropyelogram
– Retrograde
– Antegrade
Ureteral Trauma
Diagnostic Tests and Imaging

43. • Grade 1: Contusion (without devascularization)
Hematoma (without devascularization)
• Grade 2: Laceration (<50% transection)
• Grade 3: Laceration (≥50% transection)
• Grade 4: Laceration (complete transection with <2cm devascularization)
• Grade 5: Laceration (avulsion with >2cm devascularization)
Advance one grade for bilateral injuries up to grade 3
Ureteral Trauma
AAST Organ Injury Severity Scale

44. • Factors to consider in determining treatment:
– Etiology
– Level of ureter involved
– Immediate vs delayed Dx
– Severity (contusion vs. complete transection)
– Clinical status of patient
• Temporary PCN
• Remove suture/clip
• Ureteral stent insertion
Ureteral Injury
Management

45. • Ureteroneocystostomy
– ± Psoas hitch
– ± Boari flap
• Ureteroureterostomy
• Transureteroureterostomy
• Renal descensus
• Ileal interposition
• Autotransplantation
• Nephrectomy (last resort)
Ureteral Injury
Surgical Options

46. • Early
– Hydronephrosis
– Urinoma
– Infection
• Late
– Stricture
– Loss of renal function
– Stone formation
Ureteral Injury
Complications

48. • Usually due to blunt trauma
– Sports, fights
• Testis involved in 1-2% of gunshot wounds
• Pain, scrotal hematoma, bruising
• Physical exam often difficult due to pain and
degree of swelling
• U/S most useful investigation
– To determine if ruptured
– May miss tunical fracture
Testis Trauma

49. • Grade 1: Contusion
Hematoma
• Grade 2: Subclinical laceration of tunica albuginea
• Grade 3: Laceration of TA with <50% parenchymal loss
• Grade 4: Major laceration of TA with ≥50% parenchymal loss
• Grade 5: Total testicular destruction or avulsion
Advance one grade for bilateral injuries up to grade 5
Testis Trauma
AAST Organ Injury Severity Scale

50. • Most cases are low grade injuries (contusions or
hematomas) and are therefore managed non-
operatively
– Ice, analgesics, bedrest/activity restrictions
• Indications to operate:
– Rupture of tunica albuginea
– Expanding or large hematocele
– Intratesticular hematoma
• Surgery
– Repair vs. orchidectomy
Testicular salvage rate higher for early exploration
Testis Trauma
Management