Urological Injuries


Renal Trauma

ASST Organ injury scale for renal trauma

 

Grade

Injury

I

Non-expanding subcapsular haematoma without parenchymal laceration

Contusion with microscopic or gross haematuria and normal investigations

II

Laceration <1cm parenchymal depth without urinary extravasation

III

Laceration >1cm without collecting system rupture

IV

Laceration extending into the collecting system with urinary extravasation; injury to main renal vessel with contained haemorrhage

V

Shattered kidney; avulsion of renal hilum with devascularization

 Grade I-II usually managed nonoperatively


Evaluation


1. Haematuria is the standard marker for renal injury; perform in all patients
- bladder and ureter may also show haematuria.
- may not occur with injuries to the proximal renal vasculature.


2. Blunt trauma
- beware deceleration injury; renal pelvis / uretopelvic jx injury
- look for flank ecchymosis, lower rib fractures, transverse process #


3. Penetrating trauma
- identify wounds with radio-opaque markers to help imaging
- high risk in posterior wounds; anterior usually hit other structures first.


4. Indications for renal imaging:
- blunt trauma and gross haematura
- blunt trauma, haematuria, shock
- major accleration or deceleration injury
- any haematuria after penetrating injury
- associated injuries and physical signs


5. Imaging
- CT: best choice
- arteriographic phase for hulum injuries, blush.
- renal vein injuries identified by haematoma medial to kidney.
- USS: blood in Gerota will not show in FAST not effective for kidneys
- IVU replaced by CT, but may do a well timed IVU prior to theatre to confirm contralateral kidney fx(?)
- arteriography used for intervention.


6. Instability
- no need for imaging; laparotomy.


7. Indications for renal exploration
- vast majority can be managed non-operatively
- absolute = peristent life threatening bleeding

- including pulsatile / expanding or uncontained retroperitoneal haematoma.
- relative = devitalized parenchyma >50%, urinary extravasation not resolving (25% or so) - usually stented though if possible; arterial thrombosis; penetrating injuries


Surgical Management
 
1. Retroperitoneal injuries

image
Zone of haematoma dictates operative approach
Zone 1
High risk of vascular injury, explore unless small and stable
Medial visceral rotation L or R depending on site of haematoma
- if over aorta, Maddox, if over IVC then Cattel-Brasch and Kocher
- helpful to have supraceliac access for proximal control
Zone II (renal injury)
Penetrating: selective; if blunt and stable, observe, f/up imaging
- if haemorrhage controlled and bowel contamination limited
- can leave the contained zone II injury alone; pack, damage control, angiography when resuscitated.
- if massive renal injury, may need lifesaving nephrectomy
Zone III
- associated with pelvic #
- blunt: do not explore or anticipate release of tamponade and death by exsanguination
- penetrating: explore and control

2 Exsanguinating injury?
- direct immediate manual control; then delay all strategies to get clamps on vessels and expose renal and other injuries for resection and repair until resuscitation catch up
- put proximal aorta clamp on to buy minutes of time.
- mobilize kidney laterally from Gerota laterally, manual compression and clamp on hilum.

Injuries to the renal jilum are uncommon and challenging
- need specialist input, often need patch repair / grafts

3. No exsanguinating bleed
- no need for proximal control in general; sdisplace small bowel along root of mesentery and laterally to right.
- take down the ligament of treiz


Non-Operative Management
Recent evidence suggests that  bed rest can be avoided unless bleeding appreciably increases or resumes after ambulation.


Complications

- prolonged urine extravasation; large >4cm are prone to sepsis and should be drained
- other complications include delayed bleeding, arterial pseudoaneurysm, urinary fistula, hydronephrosis

- follow up CT for delayed hydronephrosis, vascular compromise, renal atrophy.
- hypertension; can be transitory


Rest of Jerome's Notes

· Can affect

— Parenchyma

— Capsule

— Pedicle

· Either Penetrating or blunt. Blunt most common.

· Risk of renal trauma is greater in children

· Mechanism of injury, haematuria (gross or microscopic) or associated injuries (lower rib #) should raise the possibility of renal trauma.

· Haematuria is the most sensitive indicator of injury but does not predict severity.

· Radiographic investigation is required in:

· Macroscopic haematuria

· Microscopic haematuria and episode of SBP<90

· Microscopic haematuria and SBP>90 with suspicious mechanism of injury, or physical exam (lower rib # or flank bruise).

CT is the best study with IV contrast. An arterial phase and a 10min delayed scan to detect collecting system injury.

Single shot IVP

· 2ml/Kg of IV contrast is given and then a KUB is taken 10 minutes later.

· Used for unstable patient who is to proceed to theatre for immediate exploration. Its major value is in assuring that contralateral kidney is functional.

Penetrating

· Classification

— Perforating

— Lacerating

— Explosive

· Often complicated by perforation of other structures

— (90% gunshot, 60% stab)

— R side

Liver/colon (60%)

— L side

Spleen/stomach/pancreas (60%)

— Chest (20%)

Clinical

· Shock 30%

· Associated injuries 70%

· Gross haematuria 60%

· Renal or clot colic

— Micro haematuria ³20%

v NB absence of blood does NOT exclude injury

Blunt

Classification

Mechanism

· Direct

· Indirect

Severity

· Major

— pedicle rupture, pelvic tears, lacerations

· Minor

— Contusions, small subcapsular haematomas

Aetiology

· Acceleration/deceleration

— Intimal tear ® renal artery thrombosis

— Artery 70%

— Vein 20%

— Both 10%

— Mortality » 50%

Clinical

· Shock 5%

· Associated injuries 15%

· Gross haematuria

· Micro haematuria

Ix

· Urinalysis

· IVP single shot

— Extravasation / non visualisation

· CT

Rx

Haemodynamically stable patients can most often be managed non-operatively

Grade I-IV injuries often managed non-operatively.

Indications for exploration:

· Unstable with renal haemorrhage

· Penetrating injury

· Expanding or pulsatile retroperitoneal haematoma at laparotomy

· Grade V injuries

Operative principles

· Mobilize colon to expose Gerota’s fascia

· Manual compression of hilum followed by clamping – about 45minutes of warm ischaemic time is tolerated.

· Open Gerota’s fascia

· Nephrectomy: Grade V injuries, continuing haemodynamic instability.

· Repair for all other injuries if possible: haemostasis, debridement, collecting system repair & pledgeted bolstered closure of the renal capsule.

Complications

Immediate: bleeding – leave a closed suction drain

Early: Ileus, infection, pneumonia, secondary bleeding, urinoma – can usually be managed expectantly and some cases will require drainage, stenting or later exploration

Late:

AV malformation – usually heralded by bleeding at 3-4 weeks (treat with selective embolization)

Hypertension <2% (within first several month) from either renal artery stenosis, renal parenchyma compression, or AVM (chronic renal ischaemia leads to rennin release).

 


Ureter

Classification

Iatrogenic

Penetrating

· Associated with other injuries

— Small bowel 80%

— Colon 60%

— IVC 20%

GSW much more common than SW

Blunt

· < 10% of injuries

Clinical

· Abdo pain

· Fever

· Haematuria

· Delayed presentation often occurs with fever, flank pain, urioma, renail failure, ileus, urinary fistula

Ix

· IVP

· Retrograde pyelogram

Rx

· If a ureteric injury is suspected during laparotomy then inject indigo carmine and look for leakage of blue dye.

Damage control:

· Only perform a definitive reconstruction if the patient is stable

· Otherwise ligate ureter, drain retroperitoneum and bladder and place a perc nephrostomy

Definitive repair

· Lower

— Reimplantation – if the ureter is too short use a vesio-psoas hitch or Boari flap

· Mid

   Primary anastomosis – spatulated end-to-end

   Transuretoureterostomy

— ± renal mobilisation

· Proximal

— Primary anastomosis

   ± pyeloplasty and renal mobilization

Or complex injury

kidney Autotransplant

Ileal interposition

ureterocalicostomy

 


Psoas Hitch

Distal ureter loss; to bridge gap
Apex of bladder sutured to the ipsilateral psoas tendon; contralateral superior vesicle pedicle divided to improve bladder mobility; care not to trap genitofemoral nerve.
 


 

 

Principles of definitive repair are

tension free

mucosa-to mucosa

spatulated (cut the tube longitunally so allowing greater circumference to join)

stented

drained

using absorbable suture.

 



Bladder

Causes:

Iatrogenic

Penetrating injury

Blunt trauma

· 75% of bladder injuries

· 10% of pts with pelvic #

· Direct blow, full bladder

Signs

-       Haematuria

-       Suprapubic pain

-       Inability to void

-       Incomplete recovery of catheter irrigation

Rupture

· Extraperitoneal:

Location: bladder base and parasymphyseal area

from pelvic symphseal # or ramus #

Treated with IDC for 10 days then reimaging to confirm healing

· Intraperitoneal:

            Locations: Dome of bladder

            From full bladder and direct blow

            Laparotomy for repair

Ix

· Haematuria

· Exclude urethral injury

· Retrograde cystourethrography (If suspected upper tract injury, do IVP first):

            Fill bladder with 400ml of 50% diluted contrast

            AP/Oblique/Lateral views + post-voiding film

            Sunburst pattern for intraperitoneal rup: contrast in SB loop, gutters, organs

            Contrast leaking adjacent to symphysis for extraperiotneal injury

· CT cystography

Rx

· IDUC/SPC

· Primary repair



 

Urethra

Common in Male than Female due to length of urethra

Mechanism

-       Crushing/deceleration injury

-       Staddle

-       Pelvic #

§  Commonly rupture at prostatomembraneous uethra

-       During Sexual intercourse

Signs

-       Haematuria

-       Bruise or Swelling penis or scrotum

-       PR: high riding prostate

-       Inability to void

-       Inability to pass catheter

Rx

· Incomplete transaction (Regardless site)

Stenting across the defect

or

Diversion with suprapublic cystostomy

· Complete transaction

            Always needs suprapubic cystostomy

            Endoscopic bridging IDC

Complications

· Structure

· Incontinence

· Impotence

 

Posterior

Classification

· Urogenital diaphragm

· Ext sphincter

· Prostatic

Associations

· 5% of pts with pelvic #

· 50% with disruption of pelvic rim

Ix

· Rectal

— Boggy mass

— Mobile prostate

· Retrograde urethrogram prior to insert IDC

Rx

· Controversial

— Pass/not pass IDUC

— SPC

— Primary repair

Anterior

Classification

· Bulbar

· Pendulous

Aetiology

· Iatrogenic

· Straddle

· (gunshot !)

Pathology

· Extravasation within Colles’ fascia

Clinical

· Pain

· Swelling

· Echymosis

· Blood urethral meatus

· Inability to void

Trauma 34

Ix

· Retrograde urethrogram

Rx

· Partial seperation

— Silastic IDC, antibiotics

· Full seperation

— Perinieal incision, drainage and primary repair