Urological

Trauma N. Djakovic, E. Plas, L. Martínez-Piñeiro, Th. Lynch, Y. Mor, R.A. Santucci, E. Serafetinidis, L.N. Turkeri, M. Hohenfellner

© European Association of Urology 2009Table of ConTenTs Page 1. INTRODUCTION 6

1.1 Reference 6

2. RENAL TRAUMA 6

2.1 Background 6

2.2 Mode of injury 7

2.2.1 Injury classification 7

2.3 Diagnosis: initial emergency assessment 7

2.3.1 History and physical examination 8

2.3.2 Recommendations 8

2.3.3 Laboratory evaluation 8

2.3.4 Recommendations 9

2.3.5 Imaging: criteria for radiographic assessment in adults 9

2.3.5.1 Ultrasonography 9

2.3.5.2 Standard IVP 10

2.3.5.3 One-shot intraoperative IVP 10

2.3.5.4 Computed tomography (CT) 10

2.3.5.5 Magnetic resonance imaging (MRI) 11

2.3.5.6 Angiography 11

2.3.5.7 Radionuclide scans 11

2.3.6 Recommendations 12

2.4 Treatment 12

2.4.1 Indications for renal exploration 12

2.4.2 Operative findings and reconstruction 12

2.4.3 Non-operative management of renal injuries 13

2.4.4 Recommendations 14

2.4.5 Post-operative care and follow-up 14

2.4.6 Recommendations 14

2.4.7 Complications 15

2.4.8 Recommendations 15

2.4.9 Paediatric renal trauma 15

2.4.10 Recommendations 17

2.4.11 Renal injury in the polytrauma patient 17

2.4.12 Recommendations 17

2.5 Iatrogenic renal injuries 17

2.5.1 Iatrogenic vascular injuries 17

2.5.2 Renal transplantation 18

2.5.3 Percutaneous renal procedures 18

2.5.4 Recommendations 20

2.6 Suggestions for future research studies 20

2.7 Algorithms 20

2.8 References 23

3. URETERAL TRAUMA 31

3.1 Introduction 31

3.2 Aetiology 32

3.3 Diagnosis 32

3.3.1 Clinical diagnosis 32

3.3.2 Radiological diagnosis 32

3.4 Classification 32

3.5 Management 32

3.5.1 Partial injuries 32

3.5.2 Complete injuries 33

3.5.3 Sterile surgery 33

3.5.3.1 Uretero-ureterostomy 33

3.5.3.2 Ureterocalycostomy 34

3.5.3.3 Transuretero-ureterostomy 34 2 UPDATE MARCH 20093.5.3.4 Ureteroneocystostomy with Boari flap 34

3.5.3.5 Ureterocystostomy and psoas hitch 34

3.5.3.6 Ileal interposition graft 34

3.5.3.7 Autotransplantation 35

3.5.3.8 Nephrectomy 35

3.6 References 35

4. BLADDER TRAUMA 35

4.1 Background 35

4.1.1 Iatrogenic trauma 36

4.2 Classification 37

4.3 Risk factors 37

4.4 Diagnosis 37

4.4.1 Macroscopic (gross) haematuria 37

4.4.2 Microscopic haematuria 38

4.4.3 Cystography 38

4.4.4 Excretory urography (intravenous pyelogram [IVP]) 38

4.4.5 Ultrasound (US) 38

4.4.6 Computed tomography (CT) 38

4.4.7 Angiography 39

4.4.8 Magnetic resonance imaging (MRI) 39

4.4.9 Cystoscopy 39

4.5 Treatment 39

4.5.1 Blunt trauma: extraperitoneal rupture 39

4.5.2 Blunt trauma: intraperitoneal rupture 39

4.5.3 Penetrating injuries 39

4.5.4 Iatrogenic injuries 39

4.6 Recommendations 40

4.6.1 General 40

4.6.2 Diagnosis 40

4.6.3 Treatment 40

4.7 References 40

5. URETHRAL TRAUMA 44

5.1 Anatomical and aetiological considerations 44

5.1.1 Posterior urethral injuries 44

5.1.1.1 Urethral injuries in children 46

5.1.1.2 Urethral injuries in women 46

5.1.1.3 Penetrating injuries to the perineum 46

5.1.2 Anterior urethral injuries 46

5.1.2.1 Blunt trauma 46

5.1.2.2 Intercourse-related trauma 47

5.1.2.3 Penetrating trauma 47

5.1.2.4 Constriction band-related trauma 47

5.1.2.5 Iatrogenic trauma 47

5.2. Diagnosis: initial emergency assessment 47

5.2.1 Clinical assessment 47

5.2.1.1 Blood at the meatus 47

5.2.1.2 Blood at the vaginal introitus 47

5.2.1.3 Haematuria 47

5.2.1.4 Pain on urination or inability to void 48

5.2.1.5 Haematoma or swelling 48

5.2.1.6 High-riding prostate 48

5.2.2 Radiographic examination 48

5.2.3 Endoscopic examination 49

5.3. Management 49

5.3.1 Anterior urethral injuries 49

5.3.1.1 Blunt injuries 49

5.3.1.2 Open injuries 49

5.3.1.2.1 Male urethral injuries 49 UPDATE MARCH 2009 35.3.1.2.2 Female urethral injuries 50

5.3.2 Posterior urethral injuries 50

5.3.2.1 Partial urethral rupture 50

5.3.2.2 Complete urethral rupture 50

5.3.2.3 Primary realignment 51

5.3.2.4 Immediate open urethroplasty 53

5.3.2.5 Delayed primary urethroplasty 53

5.3.2.6 Delayed urethroplasty 53

5.3.2.7 Reconstruction of failed repair of posterior urethral rupture 54

5.3.2.8 Delayed endoscopic optical incision 55

5.4 Recommendations for treatment: algorithms 56

5.5 Iatrogenic urethral trauma 58

5.5.1 Introduction 58

5.5.2 Iatrogenic urethral trauma caused by catheterisation 58

5.5.3 Iatrogenic urethral trauma caused by transurethral surgery 59

5.5.4 Iatrogenic urethral trauma related to surgical prostate cancer treatment 59

5.5.5 Iatrogenic urethral trauma related to radiotherapy for prostate cancer treatment 59

5.5.6 Iatrogenic urethral trauma related to major abdominal surgery 59

5.5.7 Symptoms of iatrogenic urethral injury 59

5.5.8 Diagnosis 60

5.5.9 Treatment 60

5.5.10 Recommendations for treatment: algorithms 60

5.5.11 Recommendations 61

5.6 References 61

6. GENITAL TRAUMA 69

6.1 Background 69

6.2 Pathophysiology 69

6.2.1 Blunt trauma 69

6.2.2 Penetrating trauma 70

6.3 Risk factors 71

6.4 Diagnosis 71

6.4.1 Blunt renal trauma 71

6.4.1.1 Penile fracture 71

6.4.2 Blunt testicular trauma 71

6.4.3 Blunt female trauma 72

6.4.4 Penetrating trauma 72

6.5 Treatment 72

6.5.1 Penile trauma 72

6.5.1.1 Blunt trauma 72

6.5.1.2 Penetrating trauma 72

6.5.2 Testicular trauma 72

6.5.2.1 Blunt trauma 72

6.5.2.2 Penetrating trauma 73

6.5.3 Vulvar injuries 73

6.6. References 73

7. MASS CASUALTY EVENTS, TRIAGE AND DAMAGE CONTROL 76

7.1 Definition 76

7.2 Causes of mass casualty events 76

7.3 Mechanisms of explosive injury 77

7.4 Triage 77

7.4.1 Primary triage 77

7.4.2 Secondary triage 77

7.4.3 Re-triage 77

7.5 Principles of ‘damage control’ 78

7.6 Urological aspects of ‘damage control’ 78

7.6.1 The urological consultation in the emergency room during mass casualty events 78

7.6.1.1 Responsibility and primary overall assessment 78

7.6.1.2 Imaging 78 4 UPDATE MARCH 20097.6.1.3 Primary management 78

7.6.2 The urological consultation in the operating room during mass casualty events 79

7.6.2.1 Renal trauma 79

7.6.2.2 Ureteral injuries 80

7.6.2.3 Bladder injury 81

7.6.2.3.1 Auxiliary damage control measures 81

7.6.2.4 Urethral injury 81

7.6.2.5 Injury of the external genitalia 81

7.6.2.5.1 Temporary damage control measures 81

7.7 Summary 81

7.8 References 81

8. ABBREVIATIONS USED IN THE TEXT 84 UPDATE MARCH 2009 51. inTroduCTion

1.1 background

The European Association of Urology (EAU) Guidelines Group for Urological Trauma prepared this guidelines document to assist medical professionals in the management of urological trauma.

The Urological Trauma guidelines are based on a review of the literature, using on-line searches of MEDLINE and other source documents published between 2005 and 2008. A critical assessment of the findings was made, not involving a formal appraisal of the data. There is a paucity of high-powered randomized controlled trials in this area and considerable available data are based on retrospective studies. The panel recognise this limitation.

A level of evidence (LE) and/or grade of recommendation (GR) have been assigned where possible (1).

The aim of grading recommendations is to provide transparency between the underlying evidence and the recommendation given.

Publication history information: The Urological Trauma Guidelines were first published in 2003, with a partial update in 2006 followed by this full text update in 2009. Additionally, a quick reference guide is available.

All texts can be viewed and downloaded for personal use at the society website: http://www.uroweb.org/ professional-resources/guidelines/.

levels of evidence and grade of guideline recommendations*

Table 1: level of evidence

level Type of evidence

1a Evidence obtained from meta-analysis of randomised trials

1b Evidence obtained from at least one randomised trial

2a Evidence obtained from one well-designed controlled study without randomisation

2b Evidence obtained from at least one other type of well-designed quasi-experimental study

3 E vidence obtained from well-designed non-experimental studies, such as comparative studies,

correlation studies and case reports

4 E vidence obtained from expert committee reports or opinions or clinical experience of respected

authorities

Table 2: grade of recommendation

grade nature of recommendations

A B ased on clinical studies of good quality and consistency addressing the specific recommendations

and including at least one randomised trial

B Based on well-conducted clinical studies, but without randomised clinical trials

C Made despite the absence of directly applicable clinical studies of good quality

*modified from Sackett et al. (1)

1.1 referenCe

1. Oxford Centre for Evidence-based Medicine Levels of Evidence (May 2001). Produced by Bob

Phillips, Chris Ball, Dave Sackett, Doug Badenoch, Sharon Straus, Brian Haynes, Martin Dawes since November 1998.

http://www.cebm.net/index.aspx?o=1025 [accessed February 2009].

2. renal TrauMa

2.1 background

Renal trauma occurs in approximately 1-5% of all trauma cases (1, 2). The kidney is the most commonly injured genitourinary and abdominal organ. There is a 3:1 male to female ratio in kidney trauma patients (3-5). Renal trauma can be acutely life-threatening, but the majority of renal injuries can be managed conservatively. Advances in imaging and treatment strategies during the past 20 years have decreased the need for surgical intervention and increased renal preservation (6-8).

6 UPDATE MARCH 2009

2.2 Mode of injury

Renal injuries are classified by their mechanism: blunt or penetrating. In rural settings, blunt trauma can account for the largest percentage (90-95%) (9), while in urban settings, the percentage of penetrating injuries can increase to 20% (6) or higher.

Blunt trauma is usually caused by motor vehicle accidents, falls, vehicle-associated pedestrian accidents, contact sports and assault. Traffic accidents are the major cause of almost half the blunt renal injuries (10). Renal injury in frontal and side-impact collisions appears to occur after direct impact from objects in the vehicle compartment. For frontal crashes, occupant acceleration into the seat belt or steering wheel seems to result in renal injuries. Side impact injuries occur when the vehicle side panel intrudes into the compartment, striking the occupant (11). A 20-year review of renal injuries following free falls found a rate of 16% (12).

Renal lacerations and renal vascular injuries make up only 10-15% of all blunt renal injuries. Isolated renal artery injury following blunt abdominal trauma is extremely rare, and accounts for less than 0.1% of all trauma patients (13).

Renal artery occlusion is associated with rapid deceleration injuries. In theory, the kidney is displaced causing renal artery traction; the resulting tear in the inelastic intima and subsequent haemorrhage into the vessel wall leads to thrombosis. Compression of the renal artery between the anterior abdominal wall and the vertebral bodies may result in thrombosis of the renal artery.

Gunshot and stab wounds represent the most common causes of penetrating injuries. Renal injuries from penetrating trauma tend to be more severe and less predictable than those from blunt trauma. Bullets, because of their higher kinetic energy, have the potential for greater parenchymal destruction and are most often associated with multiple-organ injuries (14).

In wartime, the kidney is the most commonly injured urogenital organ. Most are found to be associated with major abdominal injuries, and the rate of wartime nephrectomies is relatively high (25-33%) (15-17).

2.2.1 injury classification

Classifying renal injuries helps to standardise different groups of patients, select appropriate therapy and predict results. A total of 26 classifications for renal injuries have been presented in the literature in the past 50 years (18), but the committee on organ injury scaling of the American Association for the Surgery of Trauma (AAST) has developed a renal-injury scaling system that is now widely used (19). Renal injuries are classified as grade 1 to 5 (Table 3). Abdominal computed tomography (CT) or direct renal exploration is used to classify injuries. Most recent publications in the field of renal trauma have adopted this classification. In a retrospective review, the AAST scaling system was determined as the most important variable predicting the need for kidney repair or removal (20, 21). It also predicts for morbidity after blunt or penetrating injury, and for mortality after blunt injury (22).

Table 3: aasT renal injury grading scale (17)

grade* description of injury

1 • Contusion or non-expanding subcapsular haematoma

• No laceration

2 • Non-expanding peri-renal haematoma

• Cortical laceration < 1 cm deep without extravasation

3 • Cortical laceration > 1 cm without urinary extravasation

4 • Laceration: through corticomedullary junction into collecting system

or

• V ascular: segmental renal artery or vein injury with contained haematoma, or partial vessel laceration, or vessel thrombosis

5 • Laceration: shattered kidney

or

• Vascular: renal pedicle or avulsion

*Advance one grade for bilateral injuries up to grade III.

2.3 diagnosis: initial emergency assessment

Initial assessment of the trauma patient should include securing the airway, controlling external bleeding and resuscitation of shock, as required. In many cases, physical examination is carried out during the stabilisationof the patient. When renal injury is suspected, further evaluation (CT scan, laparotomy) is required for a prompt diagnosis.

2.3.1 History and physical examination

A direct history is obtained from conscious patients. Witnesses and emergency personnel can provide valuable information about unconscious or seriously injured patients. Possible indicators of major renal injury include

a rapid deceleration event (fall, high-speed motor vehicle accidents) or a direct blow to the flank. In assessing trauma patients after motor vehicle accidents, the history should include the vehicle’s speed and whether the patient was a passenger or pedestrian.

In penetrating injuries, important information includes the size of the weapon in stabbings, and the type and calibre of weapon used in gunshot wounds, as high-velocity projectiles have the potential to cause more extensive damage.

The medical history should be as detailed as possible, as pre-existing organ dysfunction can have a negative effect on trauma patient outcome (23). In the early resuscitation phase, special consideration should be given to pre-existing renal disease (24). Another point of interest is the functioning renal mass of the trauma patient, as there are numerous case reports in the literature about complicated renal trauma in solitary kidneys (25).

Pre-existing renal abnormality makes renal injury more likely following trauma. Pre-existing renal pathology should be noted. Hydronephrosis due to ureteropelvic junction abnormality, renal calculi, cysts and tumours are the most commonly reported entities that may complicate a minor renal injury (26). The overall percentage of these cases varies from 4% to 22% (27, 28).

Haemodynamic stability is the primary criterion for the management of all renal injuries. Shock is defined as a systolic blood pressure of less than 90 mmHg found at any time during an adult patient’s evaluation. Vital signs should be recorded throughout diagnostic evaluation.

Physical examination may reveal an obvious penetrating trauma from a stab wound to the lower thoracic back, flanks and upper abdomen, or bullet entry or exit wounds in this area. In stab wounds, the extent of the entrance wound may not accurately reflect the depth of penetration. Blunt trauma to the back, flank, lower thorax or upper abdomen may result in renal injury. The following findings on physical examination could indicate possible renal involvement:

• haematuria

• flank pain

• flank ecchymoses

• flank abrasions

• fractured ribs

• abdominal distension

• abdominal mass

• abdominal tenderness.

2.3.2 recommendations

2.3.3 laboratory evaluation

The trauma patient is evaluated by a series of laboratory tests. Urinalysis, haematocrit and baseline creatinine are the most important tests for evaluating renal trauma.Urinalysis is considered the basic test in the evaluation of patients with suspected renal trauma. Haematuria

is the presence of an abnormal quantity of red blood cells in the urine and is usually the first indicator of renal injury. Microscopic haematuria in the trauma setting may be defined as greater than 5 red blood cells per high-power field (rbc/hpf), while gross haematuria is demonstrated by urine in which blood is readily visible.

Haematuria is a hallmark sign of renal injury, but is neither sensitive nor specific enough for differentiating minor and major injuries. It does not necessarily correlate with the degree of injury (29). Major renal injury, such as disruption of the ureteropelvic junction, renal pedicle injuries or segmental arterial thrombosis may occur without haematuria (30). In a study by Eastham et al., 9% of patients with stab wounds and resultant proven renal injury did not manifest haematuria (31). Haematuria that is out of proportion to the history of trauma may suggest pre-existing renal pathology (32). A urine dipstick is an acceptably reliable and rapid test to evaluate haematuria. However, some studies have shown false-negative result rates ranging from 3-10% using the dipstick test for haematuria (33).

Serial haematocrit determination is a method of continuous evaluation of the trauma patient. Initial haematocrit in association with vital signs implies the need for emergency resuscitation. The decrease in haematocrit and the requirement for blood transfusions is an indirect sign of the rate of blood loss and, along with the patient’s response to resuscitation, is valuable in the decision-making process.

As most trauma patients are evaluated within 1 hour of injury, creatinine measurement reflects renal function prior to the injury. An increased creatinine usually reflects pre-existing renal pathology.

2.3.4 recommendations

2.3.5 imaging: criteria for radiographic assessment in adults

Decisions about radiographic imaging in cases of suspected renal trauma are based on the clinical findings and the mechanism of injury. Since the majority of renal injuries are not significant and resolve without any intervention, many attempts have been made to identify which patients could be spared the discomfort, radiation exposure, possible allergic reaction, time and expense of a radiographic evaluation (34).

Some patients do not require radiographic evaluation following blunt renal trauma. Patients with microscopic haematuria and no shock after blunt trauma have a low likelihood of concealing significant renal injury (35). The indications for radiographic evaluation are gross haematuria, microscopic haematuria and shock, or the presence of major associated injuries (36). However, patients with a history of rapid deceleration injury with clinical indicators of renal trauma or associated injuries also need immediate imaging to rule out ureteral avulsion or renal pedicle injury (12).

Patients with penetrating trauma to the torso have a high incidence of significant renal injuries. If renal injury is clinically suspected on the basis of an entry or exit wound, renal imaging should be performed, regardless of the degree of haematuria (37).

2.3.5.1 Ultrasonography

Ultrasonography is a popular imaging modality in the initial evaluation of abdominal trauma. It provides a quick, non-invasive, low-cost means of detecting peritoneal fluid collections without exposure to radiation (38). However, the usefulness of conventional ultrasound in the radiographic evaluation of renal trauma has been widely questioned. Its limitations stem from the difficulty in obtaining good acoustic windows on trauma patients who have sustained numerous associated injuries. The results are also highly dependent on the operator.

Ultrasound scans can detect renal lacerations but cannot definitely assess their depth and extent and do

not provide functional information about renal excretion or urine leakage. Despite the drawbacks of the method, ultrasound scans can be conveniently used during the primary assessment of renal injuries. Duringthe evaluation of blunt trauma patients, ultrasound scans were more sensitive and specific than standard intravenous pyelography (IVP) in minor renal trauma (39). In another study comparing the results of ultrasound scans and IVP, the sensitivity of ultrasound decreased as the severity of the trauma increased, while that of IVP remained high for all degrees of severity (40).

Another possible role for ultrasound may be for serially evaluating stable renal injuries for the resolution of urinomas and retroperitoneal haematomas (41). Ultrasound might be considered suitable for the routine follow-up of renal parenchymal lesions or haematomas in the intensive care unit. Contrast-enhanced sonography

is more sensitive than conventional ultrasound in the detection of renal injuries. In haemodynamically stable patients, it is a useful tool in the assessment of blunt injuries (42).

In conclusion, since ultrasound scans are used in the triage of patients with blunt abdominal trauma in many centres, they can be helpful in identifying which patients require a more aggressive radiological exploration to obtain a certain diagnosis (43, 44). Ultrasound findings do not provide sufficient evidence for a definite answer on the severity of renal injuries.

2.3.5.2 Standard IVP

Standard IVP is no longer the study of choice for the evaluation of renal trauma. In some centres it may be the only study available, in which case IVP should establish the presence or absence of one or both of the kidneys, clearly define the renal parenchyma, and outline the collecting system. In order to stage renal trauma, the IVP should include nephrotomograms, delineate the renal contour, and visualise the excretion of contrast material from both kidneys into the renal pelvis and ureter. Non-visualisation, contour deformity, or extravasation

of contrast implies a major renal injury and should prompt further radiological evaluation with CT or, less commonly, angiography if available.

The most significant findings on IVP are non-function and extravasation. Non-function is usually a sign of extensive trauma to the kidney, pedicle injury (vascular avulsion or thrombosis), or a severely shattered kidney. Extravasation of the contrast medium also implies a severe degree of trauma, involving the capsule, parenchyma and collecting system. Other less reliable signs are delayed excretion, incomplete filling, calyceal distortion and obscuring of the renal shadow. The sensitivity of IVP is high (> 92%) for all degrees of trauma severity (45).

2.3.5.3 One-shot intraoperative IVP

Unstable patients selected for immediate operative intervention (and thus unable to have a CT scan) should undergo one-shot IVP in the operating theatre. The technique consists of a bolus intravenous injection of 2 mL/ kg of radiographic contrast followed by a single plain film taken after 10 minutes. The study is safe, efficient, and of high quality in the majority of cases. It provides important information for decision-making in the critical time of urgent laparotomy concerning the injured kidney, as well as the presence of a normal functioning kidney on the contralateral side (46).

While the majority of experts advocate its use, not all studies have shown one-shot IVP to be necessary. In cases of penetrating abdominal trauma, the positive predictive value of one-shot IVP was only 20% (80% of patients with normal one-shot IVP findings had renal injuries not detected by the IVP) (47). One-shot IVP is of no significant value in assessing penetrating abdominal trauma patients who undergo exploratory laparotomy for associated intra-abdominal injuries, and should be reserved only for patients with a flank wound or gross haematuria following penetrating trauma (48).

2.3.5.4 Computed tomography (CT)

CT is the gold standard method for the radiographic assessment of stable patients with renal trauma. CT is more sensitive and specific than IVP, ultrasonography or angiography. In a retrospective study, the positive rate during evaluation of 298 patients was 96% by CT, 91% by double-dose intravenous IVP and 79% by ultrasound (45).

CT more accurately defines the location of injuries, easily detects contusions and devitalised segments, visualises the entire retroperitoneum and any associated haematomas, and simultaneously provides a view of both the abdomen and pelvis. It demonstrates superior anatomical detail, including the depth and location of renal laceration and presence of associated abdominal injuries, and establishes the presence and location of the contralateral kidney (49). CT is particularly useful in evaluating traumatic injuries to kidneys with pre-existing abnormalities (50).

Intravenous contrast should be administered for renal evaluation. A lack of contrast enhancement of the injuredkidney is a hallmark of renal pedicle injury. In cases where this typical finding is not demonstrated, central parahilar haematoma increases the possibility of renal pedicle injury. This sign should be considered even if the renal parenchyma is well enhanced (51).

Renal vein injury remains difficult to diagnose with any type of radiographic study. However, the presence on CT of a large haematoma, medial to the kidney and displacing the renal vasculature, should raise the suspicion of venous injury. Newer ‘spiral’ CT provides shorter scanning time and thus fewer artefacts in the examinations of patients who cannot co-operate adequately (52). Three-dimensional post-processing modalities allow assessment of the renal vascular pedicle by CT angiography and improve the demonstration of complex lacerations of the renal parenchyma. However, injury to the renal collecting system may be missed during routine spiral CT. In all cases of suspected renal trauma evaluated with spiral CT, repeat scans of the kidneys should be performed 10-15 minutes after contrast injection (53). Most blunt ureteral and ureteropelvic junction injuries can be identified if delayed excretory CT scans are performed (54). CT scanning is also safe as part

of the diagnostic procedure for patients with gunshot wounds who are being considered for non-operative management (55).

2.3.5.5 Magnetic resonance imaging (MRI)

Although MRI is not used in the majority of renal trauma patients, Leppäniemi et al. investigated the use

of high-field strength MRI (1.0 T) in the evaluation of blunt renal trauma (56). MRI scans were accurate in finding peri-renal haematomas, assessing the viability of renal fragments, and detecting pre-existing renal abnormalities, but failed to visualise urinary extravasation on initial examination. The authors concluded

that MRI could replace CT in patients with iodine allergy and could be used for initial staging if CT were not available (56).

In a recent study comparing CT and MRI findings, the latter clearly revealed renal fracture with non-viable fragment, and was able to detect focal renal laceration not detected on CT due to peri-renal haematoma (57).

However, MRI is not the first choice in managing patients with trauma because it requires a longer imaging time, increases the cost, and limits access to patients when they are in the magnet during the examination. MRI is therefore useful in renal trauma only if CT is not available, in patients with iodine allergy, or in the very few cases where the findings on CT are equivocal.

2.3.5.6 Angiography

CT has largely replaced the use of angiography for staging renal injuries, as angiography is less specific, more time-consuming and more invasive. Angiography is, however, more specific for defining the exact location and degree of vascular injuries and may be preferable when planning selective embolisation for the management of persistent or delayed haemorrhage from branching renal vessels (50).

Angiography can define renal lacerations, extravasation and pedicle injury. Additionally, it is the test of choice for evaluating renal venous injuries. The most common indication for arteriography is non-visualisation of a kidney on IVP after major blunt renal trauma when a CT is not available. Common causes for non-visualisation are:

• total avulsion of the renal vessels (usually presents with life-threatening bleeding)

• renal artery thrombosis

• severe contusion causing major vascular spasm.

Angiography is also indicated in stable patients to assess pedicle injury if the findings on CT are unclear, and for those who are candidates for radiological control of haemorrhage (31).

2.3.5.7 Radionuclide scans

Radionuclide scans might be helpful for documenting renal blood flow in trauma patients with severe allergy to iodinated contrast material (50), but are not generally used or required.2.3.6 recommendations

2.4 Treatment

2.4.1 indications for renal exploration

The goal in managing patients with renal injuries is to minimise morbidity and to preserve renal function.

The need for renal exploration can be predicted with accuracy with a nomogram, which uses the type of injury, transfusion requirements, blood urea nitrogen (BUN), creatinine and injury grade (58). However, the management of renal injury is usually influenced by the decision to explore or observe associated abdominal injuries (59).

A life-threatening haemodynamic instability due to renal haemorrhage is an absolute indication for renal exploration, irrespective of the mode of injury (60, 61). Other indications include an expanding or pulsatile peri-renal haematoma identified at exploratory laparotomy performed for associated injuries (this finding heralds a grade 5 vascular injury and is quite rare). A one-shot intraoperative IVP can provide valuable information. Poor visualisation or any other abnormality of the injured kidney is an indication for exploration.

Grade 5 vascular renal injuries are, by definition, regarded as an absolute indication for exploration, although a single report has suggested that patients who are haemodynamically stable at presentation but with a grade 5 parenchymal injury (shattered kidney) after blunt trauma might be safely treated conservatively (62).

The management of major renal injuries with urinary extravasation and devitalised fragments is controversial. Since these injuries are very uncommon, published series report on small numbers of patients. In recent years, it seems to have been recognised that most major injuries heal with non-operative treatment (63). Moudouni et al. suggest that an initially conservative approach is feasible in stable patients with devitalised fragments (). These injuries are, however, associated with an increased rate of complications and late surgery (65).

Persistent extravasation or urinoma are usually managed successfully with endourological techniques. Inconclusive renal imaging and a pre-existing renal abnormality or an incidentally diagnosed tumour could require surgery even after relatively minor renal injury (32).

2.4.2 operative findings and reconstruction

The overall exploration rate for blunt trauma is less than 10% (60), and may be even lower as more centres adopt a very conservative approach to the management of these patients (66). The goal of renal exploration following renal trauma is control of haemorrhage and renal salvage. Most experienced authors suggest the transperitoneal approach for surgery (67, 68). Access to the renal vascular pedicle is then obtained through the posterior parietal peritoneum, which is incised over the aorta, just medial to the inferior mesenteric vein. Temporary vascular occlusion before opening Gerota’s fascia is a safe and effective method during exploration and renal reconstruction (69). It tends to lower blood loss and the nephrectomy rate, and appears not to increase post-operative azotaemia or mortality (70). Renal reconstruction is feasible in most cases. The overall

rate of patients who have a nephrectomy during exploration is around 13%, usually in patients with penetrating injury, and higher rates of transfusion requirements, haemodynamic instability, injury severity scores and mortality (71). Other intra-abdominal injuries also slightly increase the need for nephrectomy (72). Mortality is associated with the overall severity of the injury and is not often a consequence of the renal injury itself (73).

In gunshot injuries caused by a high-velocity bullet, reconstruction can be difficult and nephrectomy is often required (14).

Renorrhaphy is the most common reconstructive technique. Partial nephrectomy is required when non-viable tissue is detected. Watertight closure of the collecting system, if open, might be desirable, although some experts merely close the parenchyma over the injured collecting system with good results. If the renal capsule is not preserved, an omental pedicle flap or peri-renal fat bolster may be used for coverage (74). In a review by Shekarriz and Stoller, the use of fibrin sealant in traumatic renal reconstruction proved to be helpful (75). Newly developed haemostatic agents such as FLOSEAL (Baxter International Inc.) that have proven useful in open and laparoscopic partial nephrectomy, might also be helpful, but are largely unproven in the trauma setting. In all cases, drainage of the ipsilateral retroperitoneum is recommended to provide an outlet for any temporary leakage of urine.

Renovascular injuries are uncommon. They are associated with extensive associated trauma and increased peri- and post-operative mortality and morbidity. Blunt renal artery injury is rare. Non-operative management should be considered as an acceptable therapeutic option (76).

Following blunt trauma, repair of grade 5 vascular injury is seldom if ever effective (77). Repair could be attempted in those very rare cases in which there is a solitary kidney or the patient has sustained bilateral injuries (78). In all other cases, nephrectomy appears to be the treatment of choice (79). In a recent review, it appears that nephrectomy for main renal artery injury has outcomes similar to those of vascular repair, and it does not worsen post-treatment renal function in the short term. Non-operative management for segmental renal artery injury results in excellent outcomes (80).

Angiography with selective renal embolisation for haemorrhage control is a reasonable alternative to laparotomy provided that no other indication for immediate surgery exists (81). Cure of haematuria after superselective transarterial embolisation is reported as high as 98% (82). Successful haemostasis by embolisation is reported to be identical in blunt and penetrating injuries (83, 84). The complication rate is minimal, and it has been proven effective for grade 4 injuries where conservative therapy failed (85). In our series, embolisation failed when applied to grade 5 injuries (85).

2.4.3 non-operative management of renal injuries

As the indications for renal exploration become clearer, non-operative management has become the treatment of choice for the majority of renal injuries. In stable patients, supportive care with bed-rest, hydration and antibiotics is the preferred initial approach (7). Primary conservative management is associated with a

lower rate of nephrectomy without any increase in the immediate or long-term morbidity (86). The failure of conservative therapy is low (1.1%) (6).

All grade 1 and 2 renal injuries can be managed non-operatively, whether due to blunt or penetrating trauma. Therapy of grade 3 injuries has been controversial, but recent studies support expectant treatment (87-). Patients diagnosed with urinary extravasation in solitary injuries can be managed without major intervention and a resolution rate of > 90% (90). Persistent bleeding is the main indication for a reconstruction attempt (91). The majority of patients with grade 4 and 5 renal injuries present with major associated injuries, and consequently experience high exploration and nephrectomy rates (92), although emerging data indicate

that many of these patients can be managed safely with an expectant approach. Although almost all grade

4 patients with penetrating injury require renal exploration, only 20% of those with blunt trauma do (93). Isolated grade 4 renal injuries represent a unique situation to treat the patient based solely on the extent of the renal injury, thus non-operative management is used more frequently. Persistent bleeding represents

the main indication for renal exploration and reconstruction. In all cases of severe renal injury, non-operative management should occur only after complete renal staging in haemodynamically stable patients (91). Penetrating wounds have traditionally been approached surgically. However, stable patients should undergo complete staging to define the full extent of the injury. Renal gunshot injuries should be explored only if

they involve the hilum or are accompanied by signs of continued bleeding, ureteral injuries, or renal pelvis lacerations (94).Low-velocity gunshot and stab wounds of minor degree may be managed conservatively with an acceptably good outcome (95). Tissue damage from high-velocity gunshot injuries, on the other hand, might be more extensive and nephrectomy could be required. Non-operative management of renal gunshot wounds in selected stable patients is associated with a high rate of success (96-98).

If the site of penetration by stab wound is posterior to the anterior axillary line, 88% of such renal injuries

can be managed non-operatively (99). Injuries to the flank are more likely to be grade 3, while injuries to the abdomen are more likely to be grade 1. A systematic approach based on clinical, laboratory and radiological evaluation might minimise negative exploration without increasing morbidity from missed injury (61). Renal stab wounds producing major renal injuries (grade 3 or higher) are more unpredictable and are associated with a higher rate of delayed complications if treated expectantly (100).

2.4.4 recommendations

2.4.5 Post-operative care and follow-up

Patients who are successfully treated conservatively carry some risk of complications. This risk correlates with increasing grade. Repeat imaging 2-4 days after trauma minimises the risk of missed complications, especially in grade 3-5 blunt renal injuries (101). However, the utility of frequent CT scanning after injury has never been satisfactorily proven. CT scans should always be performed on patients with fever, unexplained decreasing haematocrit, or significant flank pain.

Nuclear renal scans are useful for documenting and tracking functional recovery in patients following renal reconstruction before discharge from hospital (97). To detect many of the delayed complications, an excretory urogram is recommended within 3 months of major renal injury, although benefit to the patient has not yet been proven in the literature. Follow-up should involve physical examination, urinalysis, individualised radiological investigation, serial blood pressure measurement and serum determination of renal function (60, ). Follow-up examinations should continue until healing is documented and laboratory findings have stabilised, although checking for latent renovascular hypertension may need to continue for years (102).

The literature is generally inadequate on the subject of the long-term consequences of trauma on renal tissue. It appears that on histopathological evaluation, renal tissue may appear dystrophic following some cases of conservative management of minor renal injuries (103).

2.4.6 recommendations

2.4.7 Complications

Early complications occur within the first month after injury and can be bleeding, infection, peri-nephric abscess, sepsis, urinary fistula, hypertension, urinary extravasation and urinoma. Delayed complications include bleeding, hydronephrosis, calculus formation, chronic pyelonephritis, hypertension, arteriovenous fistula, hydronephrosis and pseudoaneurysms.

Delayed retroperitoneal bleeding usually occurs within several weeks of an injury or procedure and may be

life-threatening. Selective angiographic embolisation is the preferred treatment (104). Peri-nephric abscess formation is usually best managed by percutaneous drainage, although open drainage may sometimes be required (60). Percutaneous management of complications may pose less risk of renal loss than re-operation, which may lead to nephrectomy when infected tissues make reconstruction difficult.

Renal trauma is a rare cause of hypertension, mostly in young men. The frequency of post-traumatic hypertension is estimated to be less than 5% in all published series (105, 106). Hypertension may occur acutely as a result of external compression from peri-renal haematoma (Page kidney), or chronically because of compressive scar formation (Goldblatt kidney). Hypertension is usually renin-dependent and associated with parenchymal injury. Renin-mediated hypertension may occur as a long-term complication; aetiologies include renal artery thrombosis, segmental arterial thrombosis, renal artery stenosis (Goldblatt kidney), devitalised fragments and arteriovenous fistulae. Arteriography is informative in cases of post-traumatic hypertension (107). Treatment is required if the hypertension persists, and could include medical management, excision of the ischaemic parenchymal segment, vascular reconstruction, or total nephrectomy (108).

Urinary extravasation after renal reconstruction often subsides without intervention as long as ureteral obstruction and infection are not present. Ureteral retrograde stenting may improve drainage and allow healing (109). Persistent urinary extravasation from an otherwise viable kidney after blunt trauma often responds to stent placement and/or percutaneous drainage as necessary (63).

Arteriovenous fistulae usually present with delayed onset of significant haematuria, most often after penetrating trauma. Percutaneous embolisation is often effective for symptomatic arteriovenous fistulae, but larger ones may require surgery (110).

The development of pseudoaneurysm is a rare complication following blunt renal trauma. In numerous case reports, transcatheter embolisation appears to be a reliable minimally invasive solution (111, 112).

Acute renal colic from a retained missile has been reported, and can be managed endoscopically if possible (113). Other unusual late complications, such as duodenal obstruction, may result from retroperitoneal haematoma following blunt renal trauma (114).

2.4.8 recommendations

2.4.9 Paediatric renal trauma

Blunt renal trauma is the most common injury seen in children and accounts for more than 90% of renal injuries in the paediatric population (115, 116). Children are more susceptible to renal trauma than adults. Differences in anatomy and physiology, as well as the higher incidence of pre-existing renal disease, make childrenmore likely to sustain injury. The kidneys are lower in the abdomen, less well-protected by the lower ribs and muscles of the flank and abdomen, more mobile, have less protective peri-renal fat and are proportionately larger in the abdomen than in adults (117-119).

History and physical examination are very important factors in the evaluation of the paediatric patient with suspected renal trauma. Unlike adults, hypotension is an unreliable sign in children, as an outpouring of catecholamines can maintain blood pressure despite a significant volume of blood loss. Hypotension is less common in children, and significant injury can be present despite stable blood pressures (120). Another important difference from adults is that children with microscopic haematuria or normal urinalyses and

stable vital signs may have sustained significant renal injury (121). Haematuria is an important clinical sign of paediatric renal injury and is directly related to the severity of that renal injury and the presence of associated injuries (122).

The radiographic evaluation of children with suspected renal trauma is still controversial. Stein et al. proposed that all paediatric patients with any degree of haematuria should be evaluated for renal trauma (123). In contrast, Morey et al. concluded that significant injuries are unlikely in the absence of gross or significant microscopic haematuria (> 50 rbc/hpf) (124). Nguyen and Das proposed a low threshold for renal imaging following renal trauma. The instances of its use should include patients with blunt abdominal trauma with any level of haematuria, patients with associated abdominal injury regardless of the findings of urinalysis, and patients with normal urinalyses but in whom the mechanism of injury has a high index of suspicion for renal trauma (i.e. rapid deceleration event, direct flank trauma, falls from a height) (125). After studying 720 paediatric trauma cases, Santucci et al. concluded that the decision for imaging based on the adult criteria of gross haematuria, shock and significant deceleration injury is appropriate (126).

Ultrasound is considered a reliable method of screening and following the course of renal injury in paediatric patients with blunt renal trauma in Europe, although it is used much less frequently in the USA (127, 128). Ultrasound is used in some centres, mostly in stable cases with abnormal urinalyses and/or findings suggestive of a major injury (129). The diagnostic accuracy of IVP is superior to that of ultrasound, and should be performed as an emergency procedure if CT scan is not available (130).

CT is the best imaging modality, however, and those with multiple injuries or suspected renal trauma should be evaluated by contrast-enhanced CT if possible (131, 132). The use of MRI in paediatric patients with vesicoureteral reflux found that MRI at 1.5 T was better than dimercaptosuccinic acid (DMSA) scans in detecting small renal parenchymal lesions (133), although MRI has little proven use in the acute management of the trauma patient.

Conservative treatment for grade 1-2 renal injuries is clearly defined, and these injuries should be managed expectantly (134). Non-operative management results in an excellent long-term outcome in the majority of cases (135). Non-operative management of high grade renal injuries is effective and is recommended for stable children, but requires close clinical observation, serial CT, and frequent reassessment of the patient’s overall condition (136).

The length of hospital stay does not increase with worsening severity of renal injury, but is determined by

the severity of non-renal injuries (137). Haemodynamic instability and a diagnosed grade 5 injury are the strongest indications for operative management (59, 120, 136). Stable patients with urinary extravasation can also be managed expectantly since most urinomas resolve spontaneously. In cases where there is persistent leakage, the placement of a ureteral stent or percutaneous drainage is feasible and curative in most cases. Early placement of a ureteral stent can be considered for paediatric patients with blunt renal trauma who demonstrate an absence of contrast material in the ipsilateral ureter, as clinical indications for stent placement will likely develop (138).

Major kidney trauma has significant consequences on the opposite side. Post-traumatic functional evaluation by DMSA scintigraphy 8 days after major injury is a valid prognostic indicator of later function, but its clinical utility has never been established.

Children with renal injuries that fail with non-surgical therapy appear to do so in a median time of 4 hours, but the majority of patients fail within the first 24 hours (139). The failure rate of non-surgical management for renal injuries is 3% (140). Buckley and McAninch presented an algorithm for the management of paediatric renal injuries based on the 25 year experience of the San Francisco General Hospital, which is highly recommended (135) (Figure 1).Mild renal injuries do not require follow-up imaging. Follow-up is only recommended for patients with major injuries as there is an increased risk of delayed complications and loss of renal function (139).

The majority of patients with severe renal injuries develop parenchymal scars. Radionuclide scans such as DMSA can be useful in the early diagnosis of scars and consequent hypertension (141).

2.4.10 recommendations

2.4.11 renal injury in the polytrauma patient

Approximately 8-10% of blunt and penetrating abdominal injuries involve the kidneys. The incidence of associated injury in penetrating renal trauma ranges from 77-100%. Gunshot wounds are associated with organ injury more often than are stab wounds. The majority of patients with penetrating renal trauma have associated adjacent organ injuries that may complicate treatment. In the absence of an expanding haematoma with haemodynamic instability, associated multiorgan injuries do not increase the risk of nephrectomy (142).

Blunt and penetrating trauma equally contributed to combined renal and pancreatic injury, as reported by Rosen and McAninch (143). Renal preservation was achieved in most patients, and the complication rate of the series was 15% (143). A similar rate of complications (16%) was reported in patients with simultaneous colon and renal injury. In a report reviewing this combination of injuries over a period of 17 years, 58% of patients underwent an exploration, with nephrectomies performed in 16% of explorations (144).

Renal injuries seem to be rather rare in patients with blunt chest trauma. In a recent study of polytrauma patients, conservative management was safely attempted without increasing morbidity (145). In polytrauma patients undergoing partial or total nephrectomy, there is no increased mortality or renal failure rate (146).

2.4.12 recommendations

2.5 iatrogenic renal injuries

2.5.1 iatrogenic vascular injuries

Iatrogenic main renal artery injuries with perforation or rupture are rare. They are usually reported after renal artery angioplasty or stenting, and have an incidence of 1.6% (147). One case of an iatrogenic renal artery perforation as a complication of cardiac catheterisation has also been reported (148). Since most iatrogenic renal artery lesions occur during endovascular procedures, there are no reports on the clinical symptoms, but only on the angiographic findings. Arteriovenous fistulae, pseudoaneurysms, arterial dissection or contrast extravasation are the possible radiological findings in these traumatic vascular lesions.

Traditional therapy for renal perforation has been renal artery ligation followed by bypass grafting or nephrectomy, but nowadays the treatment for acute iatrogenic rupture of the main renal artery is balloon tamponade. However, in case of failure, the immediate availability of a stent graft is vital.Patients with iatrogenic operative injuries are strikingly different from those with penetrating, blunt or catheter-related vascular trauma. Renal vessels are vulnerable during oncological procedures. Factors that increase technical difficulty are previous operation, tumour recurrence, radiation exposure and chronic inflammatory changes.

Renal vein injuries during elective abdominal operations represent a serious complication with significant morbidity. Most patients with operative venous injuries have partial lacerations that can be managed

with relatively simple techniques, such as venorrhaphy. Patch angioplasty with autologous vein or polytetrafluoroethylene (ePTFE) graft may be required if venorrhaphy is not possible (149).

Some renal vascular injuries, such as pseudoaneurysms following nephron-sparing surgery, can be managed by transcatheter embolisation (150).

2.5.2 renal transplantation

The orthotopic kidney is protected from external force by muscles, Gerota’s fascia and peri-nephric fat. A renal graft is located in the lower pelvis in the iliac fossa and is therefore more susceptible to injury, especially from direct blows to the abdomen. The transplanted kidney, unlike the native kidney, is fixed in position by

a thick fibrotic capsule that develops post-transplant. Also, the transplant kidney is not suspended by the renal vessels, so deceleration events that cause pedicle injury to a native kidney are less likely to affect a transplanted kidney (151). As transplant recipients return to more active lifestyles, including a significant risk

of becoming a trauma victim, a renal graft is liable to be severely affected by trauma that might not cause any injury to a native kidney.

In transplant recipients it is very important to know patients’ baseline renal function (152). The knowledge of an abnormal renal baseline may prevent unnecessary extensive diagnostic evaluation. Radiographic evaluation should proceed as for the native kidney. The increased risk for contrast nephrotoxicity can be minimised with adequate hydration.

A CT scan is the test of choice for a stable injured transplant recipient, as it will identify renal and associated intra-abdominal injuries and will also indirectly assess renal blood flow and function. A renal duplex examination can be also very helpful for identifying isolated trauma to the transplanted kidney and for identifying renal blood flow. Radionuclide scans might reveal urine leaks and are good for assessing overall blood flow and renal function, while angiography can assess blood flow and identify specific arterial injuries. The surgical management of an injured transplanted kidney is complex. A very short vascular pedicle and ureter, dense scarring, and a fibrous capsule may prevent any attempt at the direct repair of the parenchymal, collecting system and vascular pedicle injuries. Grade 1-3 injuries can be managed non-operatively. Grade 4-5 injuries might require exploration with debridement and drainage. Major injuries could require a subcapsular nephrectomy. Renovascular injuries have a poor prognosis. Renal arteriography may be helpful with embolisation of the main artery to stop bleeding, or with more selective embolisation to salvage part of the kidney. When renal graft injury occurs, saving the patient’s life is the first priority, but saving the graft is also very important to maintain renal function.

Iatrogenic vascular injuries of renal transplants can be managed by embolisation. Angiographic embolisation often fails, and is associated with a high complication rate and high eventual nephrectomy rate (153). On the other hand, transcatheter embolisation is highly effective for biopsy-related vascular injury in the transplanted kidney.

2.5.3 Percutaneous renal procedures

Percutaneous nephrostomy is achieved in nearly all patients without major complications. Haematuria

is common for a few days, but massive retroperitoneal haemorrhage is rare. Small subcapsular renal haematomas resolve spontaneously, while arteriovenous-calyceal fistulae are best managed by angiographic embolisation.

If a nephrostomy catheter is seen to transfix the renal pelvis, the possibility of injury to a large renal artery must be considered. The misplaced nephrostomy catheter should be withdrawn over a guidewire, and renal artery embolisation might enable rapid arrest of a life-threatening haemorrhage (154). In more complex cases, CT could be used to detect possible catheter malposition and successfully guide catheter repositioning into the renal collecting system (155).

Renal pelvis injuries can occur during percutaneous nephrostomy placement. Haemorrhage can be prevented

by avoiding puncture in anticoagulated or coagulopathic patients, careful puncture on to target calyceals, and avoidance of medial punctures. A pelvic injury is less likely to happen if the dilator is not advanced further than the calyx, the peelaway sheaths are handled with care, especially when advanced around the pelviureteric junction, and kinking of the guidewires is avoided (156).

Percutaneous renal biopsy is a relatively safe procedure. Haemorrhage, arteriovenous fistula and renal capsular artery pseudoaneurysm might occur. Arteriovenous fistula might present with severe hypertension and is

managed by embolisation (157). A pseudoaneurysm should be suspected if the patient presents with flank pain and decreasing haematocrit without haematuria. Arteriography and transarterial embolisation is the appropriate therapy (158).

Percutaneous nephrolithotomy (PCNL) is a popular procedure in which stones in the renal pelvis are

removed via a nephroscope, often after ultrasonic or electrohydraulic disruption. The complications include haemorrhage, extravasation and absorption of large volumes of irrigation fluid, fever, infection, colonic perforation, arteriovenous fistulae, and pneumothorax.

Extravasation of fluid is often due to a tear in the pelvicalyceal system. A close watch on irrigation fluid input and output is required for early recognition of the complication. Termination of the procedure if the renal pelvis is torn or ruptured is a safe choice. Apart from intraoperative evaluation of serum electrolytes, acid-base status and oxygenation, the monitoring of airway pressure is a good indicator of this complication. Metabolic acidosis, hyponatraemia, hypokalaemia, peritonism and ileus are due to absorption of large volumes of irrigation fluids. Management of this complication requires close monitoring, placement of an abdominal or retroperitoneal drain, correction of acidosis and supportive measures (159).

The diagnosis of a colon injury during or after percutaneous renal surgery can be elusive because symptoms are often variable. An unrecognised or untreated colon injury can result in abscess formation, septicaemia, and/or nephrocolic or colocutaneous fistula. Surgical exploration is inevitable when the patient experiences haemorrhage, pneumoperitoneum and peritonitis.

The majority of these cases can be successfully managed conservatively. The consistent application of proper techniques, avoidance of puncturing the kidney lateral to the posterior axillary line, and puncture of the upper pole calyx when feasible, will help prevent the injuries.

Vascular injuries with renal bleeding are quite frequent and can occur at any stage of the percutaneous procedure, requiring transfusion in 1-11% of cases. A high number of punctures and incorrect choice of puncture site (access that is too medial or direct puncture of the renal pelvis) have been suggested as the cause of vascular lesions after percutaneous procedures. Renal bleeding can arise from both venous and arterial lesions. Bleeding from venous vessels could be profuse at the end of a procedure, but is generally controlled by simple measures, such as placing the patient supine to reduce abdominal compression, positioning a nephrostomy catheter, and forcing diuresis through hydration and parenteral administration of mannitol after clamping of the nephrostomy catheter. In the case of major venous trauma with massive haemorrhage, patients with concomitant renal insufficiency can be treated without open exploration or angiographic embolisation using a Council balloon catheter (160).

Arterial lesions may induce acute or late post-operative bleeding. Severe acute bleeding usually arises from injury to the anterior or posterior segmental arteries. Delayed bleeding is usually caused by interlobar and lower pole artery lesions, often arteriovenous fistulae and post-traumatic aneurysms. Duplex ultrasound and CT angiography can diagnose vascular injuries.

Hyperselective renal embolisation is considered the most appropriate technique for the treatment of iatrogenic vascular lesions. It is essential to identify the precise site of the lesion so as to be as selective as possible and reduce the risk of renal dysfunction. Hyperselective catheterisation of the renal artery branches is achieved by means of either hydrophilic 5 French catheters or coaxial systems with low profile microcatheters (2.6 French). The use of an embolic agent helps in performing a distal and irreversible occlusion with complete haemostasis. A variety of embolic materials have been used; microcoils, homologous clots, detachable balloons, polyvinyl alcohol particles, gelfoam, silicone rubber, cotton pellets and silk filaments. The choice of the embolic agent is dependent mainly on the blood flow entity at the level of the lesion, the vessel size and the operator’s experience.

Finally, complications of endopyelotomy can be classified as major (vascular injury), and minor (infection,

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2.5.4 reCoMMendaTions

2.6 suggestions for future research studies

Among the topics that would be useful subjects for future research studies are:

• b lunt trauma grade 5 patients, as it appears that some of them may benefit from non-surgical management

• the necessity and nature of follow-up imaging

• t he value of the administration of antibiotics in low-grade renal injuries selected for conservative management.

2.7 algorithms

Figure 1 is an algorithm for the management of renal trauma in children. Figures 2 and 3 show the suggested treatment of blunt and penetrating renal injuries in adults.

figure 1: algorithm for the management of paediatric renal trauma (119)

D e t e r m i n e h a e m o d y n a m i c s t a b i l i t y

M i c r o s c o p i c h a e m a t u e r i a

R e t r o p e r i t o n e a l h a e m a t o m a

P u l s a t i l e o r e x p a n d i n g

A b n o r m a l I V P

E m e r g e n c y l a p a r o t o m y O n e -s h o t I V P

G r o s s h a e m a t u e r i a

G r a d e 3-4

G r a d e 1-2

O b s e r v a t i o n

R e n a l e x p l o r a t i o n ‡

G r a d e 5

A s s o c i a t e d i n j u r i e s r e q u i r i n g l a p a r o t o m y

O b s e r v a t i o n ,b e d r e s t ,s e r i a l H t ,a n t i b i o t i c s

R e n a l i m a g i n g †

R a p i d d e c e l e r a t o n I n j u r y o r M a j o r a s s o c i a t e d i n j u r i e s

S t a b l e

S t a b l e

N o r m a l I V P

U n s t a b l e

S u s p e c t e d a d u l t b l u n t R e n a l t r a u m a *

*Suspected renal trauma results from reported mechanism of injury and physical examination.

† Renal imaging: CT scans are the gold standard for evaluating blunt and penetrating renal injuries in stable patients. In settings where the method is not available, the urologist should rely on other imaging modalities (IVP, angiography, radiographic scintigraphy, MRI).

‡ Renal exploration: Although renal salvage is a primary goal for the urologist, decisions concerning the viability of the organ and the type of reconstruction are made during the operation.

figure 2: evaluation of blunt renal trauma in adults

S u s p e c t e d a d u l t p e n e t r a t i n g R e n a l t r a u m a *

D e t e r m i n e h a e m o d y n a m i c s t a b i l i t y

S t a b l e

U n s t a b l e

R e n a l i m a g i n g †

G r a d e 3

G r a d e 4-5G r a d e 1-2

O b s e r v a t i o n ,b e d r e s t ,s e r i a l H t ,a n t i b i o t i c s A s s o c i a t e d i n j u r i e s r e q u i r i n g l a p a r o t o m y

R e n a l e x p l o r a t i o n ‡

O b s e r v a t i o n

S t a b l e

R e t r o p e r i t o n e a l h a e m a t o m a

P u l s a t i l e o r e x p a n d i n g

A b n o r m a l I V P

E m e r g e n c y l a p a r o t o m y O n e -s h o t I V P

N o r m a l I V P

*Suspected renal trauma results from reported mechanism of injury and physical examination.

† Renal imaging: CT scans are the gold standard for evaluating blunt and penetrating renal injuries in stable patients. In settings where the method is not available, the urologist should rely on other imaging modalities (IVP, angiography, radiographic scintigraphy, MRI).

‡ Renal exploration: Although renal salvage is a primary goal for the urologist, decisions concerning the viability of the organ and the type of reconstruction are made during the operation.

figure 3: evaluation of penetrating renal trauma in adults

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128. Wessel LM, Jester I, Scholz S, Arnold R, Lorenz C, Wirth H, Waag KL. [Diagnostic and therapeutic consequences of kidney injuries in pediatric blunt abdominal trauma]. Urologe A 2000;39(5):425-31.

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129. Perez-Brayfield MR, Gatti JM, Smith EA, Broecker B, Massad C, Scherz H, Kirsch AJ. Blunt traumatic hematuria in children. Is a simplified algorithm justified?. J Urol 2002;167(6):2543-6; discussion

2546-7.

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1995;25(3):214-8.

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131. Turnock RR, Sprigg A, Lloyd DA. Computed tomography in the management of blunt abdominal trauma in children. Br J Surg 1993;80(8):982-4.

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132. Carpio F, Morey AF. Radiographic staging of renal injuries. World J Urol 1999;17(2):66-70.

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133. Takeda M, Katayama Y, Tsutsui T, Takahashi H, Komeyama T, Mizusawa T, Sato S. Value of dimercaptosuccinic acid single photon emission computed tomography and magnetic resonance

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dimercaptosuccinic acid planar scintigraphy and intravenous pyelography. Eur Urol 1994;25(4):320-5.

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134. Levy JB, Baskin LS, Ewalt DH, Zderic SA, Bellah R, Snyder HM 3rd, Templeton J, Duckett JW.

Nonoperative management of blunt pediatric major renal trauma. Urology 1993;42(4):418-24.

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135. Buckley JC, McAninch JW. Pediatric renal injuries: management guidelines from a 25-year experience.

J Urol 2004;172(2):687-90; discussion 690.

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solid organ injury: a multi-institutional experience. J Trauma 2005;59(6):1309-13.

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142. Kansas BT, Eddy MJ, Mydlo JH, Uzzo RG. Incidence and management of penetrating renal trauma in patients with multiorgan injury: extended experience at an inner city trauma center. J Urol

2004;172(4Pt1):1355-60.

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143. Rosen MA, McAninch JW. Management of combined renal and pancreatic trauma. J Urol 1994;152(1):22-5.

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144. Wessells H, McAninch JW. Effect of colon injury on the management of simultaneous renal trauma. J Urol 1996;155(6):1852-6.

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145. Sartorelli KH, Frumiento C, Rogers FB, Osler TM. Nonoperative management of hepatic, splenic, and renal injuries in adults with multiple injuries. J Trauma. 2000;49(1):56-61; discussion 61-2.

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146. Cass AS, Luxenberg M, Gleich P, Smith C. Deaths from urologic injury due to external trauma. J Trauma 1987;27(3):319-21.

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147. Morris CS, Bonnevie GJ, Najarian KE. Nonsurgical treatment of acute iatrogenic renal artery injuries occurring after renal artery angioplasty and stenting. AJR Am J Roentgenol 2001;177(6):1353-7.

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148. Bates MC, Shamsham FM, Faulknier B, Crotty B. Successful treatment of iatrogenic renal artery perforation with an autologous vein-covered stent. Catheter Cardiovasc Interv 2002;57(1):39-43.

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149. Oderich GS, Panneton JM, Hofer J, Bower TC, Cherry KJ Jr, Sullivan T, Noel AA, Kalra M, Gloviczki P. Iatrogenic operative injuries of abdominal and pelvic veins: a potentially lethal complication. J Vasc Surg 2004;39(5):931-6.

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150. Taneja M, Tan KT. Renal vascular injuries following nephron-sparing surgery and their endovascular management. Singapore Med J 2008;49(1):63-6.

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151. Barone GW, Sailors DM, Hudec WA, Ketel BL. Trauma management in solid organ transplant recipients. J Emerg Med 1997;15(2):169-76.

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152. Del Pizzo JJ, Jacobs SC, Sklar GN. Ureteroscopic evaluation in renal transplant recipients. J Endourol 1998;12(2):135-8.

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153. Dorffner R, Thurnher S, Prokesch R, Bankier A, Turetschek K, Schmidt A, Lammer J. Embolization of iatrogenic vascular injuries of renal transplants: immediate and follow-up results. Cardiovasc Intervent Radiol 1998;21(2):129-34.

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154. Cowan NC, Traill ZC, Phillips AJ, Gleeson FV. Direct percutaneous transrenal embolization for renal artery injury following percutaneous nephrostomy. Br J Radiol 1998;71(851):1199-201.

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155. Jones CD, McGahan JP. Computed tomographic evaluation and guided correction of malpositioned nephrostomy catheters. Abdom Imaging 1999;24(4):422-5.

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156. Lewis S, Patel U. Major complications after percutaneous nephrostomy – lessons from a department audit. Clin Radiol 2004;59(2):171-9.

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157. Ozdemir S, Cekirge S, Kara A, Bakkaloğlu A. A rare complication of renal biopsy in a child with membranoproliferative glomerulonephritis. Int Urol Nephrol 1998;30(6):6-92.

http://www.ncbi.nlm.nih.gov/pubmed/10195861

158. Silberzweig JE, Tey S, Winston JA, Mitty HA. Percutaneous renal biopsy complicated by renal capsular artery pseudoaneurysm. Am J Kidney Dis 1998;31(3):533-5.

http://www.ncbi.nlm.nih.gov/pubmed/9506693

159. Ghai B, Dureja GP, Arvind P. Massive intraabdominal extravasation of fluid: a life threatening complication following percutaneous nephrolithotomy. Int Urol Nephrol 2003;35(3):315-18.

http://www.ncbi.nlm.nih.gov/pubmed/15160530

160. Gupta M, Bellman GC, Smith AD. Massive hemorrhage from renal vein injury during percutaneous renal surgery: endourological management. J Urol 1997;157(3):795-7.

http://www.ncbi.nlm.nih.gov/pubmed/9072568

161. Bellman GC. Complications of endopyelotomy. J Endourol 1996;10(2):177-81.

http://www.ncbi.nlm.nih.gov/pubmed/8728685

3. ureTeral TrauMa

3.1 introduction

The ureter is the sole conduit for urinary transport between the kidney and the bladder. Thus, any ureteral injury can threaten the function of the ipsilateral kidney. This small, mobile, worm-like, peristalsing, urothelial-lined tube runs inferiorly from the renal pelvis in the retroperitoneal space. It lies anterior to the muscles of the posterior abdominal wall and lateral to the vertebral column, before descending into the bony ring of the pelvis to enter the bladder. Any external injury to the flank or back and any calamity within the bony pelvis therefore places the ureter at risk. Perhaps because of its protected location, its small size and its mobility, trauma to the ureter is relatively rare and accounts for only 1% of all urinary tract trauma. Thus, there is a relatively small volume of published clinical experience upon which to base recommendations of management.3.2 aetiology

The largest and most contemporary review of ureteral trauma in the European literature is from Dobrowolski et al. in Poland (1). These authors retrospectively analyzed the records of patients with upper urinary tract injuries presenting to 61 urology departments between 1995 and 1999. They identified 452 ureteral injuries. Of these, 340 (75%) were iatrogenic, 81 (18%) were from blunt trauma, and 31 (7%) were from penetrating trauma. Of the 340 iatrogenic injuries, 247 (73%) were gynaecological in origin, 46 (14%) were general surgical and 47 (14%) were urological. It is therefore important to note that ureteral injury is much more likely to occur from activity within a hospital rather than from injuries sustained outside. Dobrowolski et al. estimate the frequency of ureteral injury during gynaecological pelvic surgical procedures to be 1.6 per 1000 (1). Of the total ureteral injuries identified, the injury was in the upper third in 60 cases (13%), in the middle third in 61 cases (13%), and in the lower third in 331 (74%). The median time to diagnosis was 3.3 h.

The most common diagnostic investigation was intravenous urography (IVU), which was used in 244 patients; retrograde ureteropyelography was used in 98 patients; and ureteral catheterization was used in 125. The diagnosis was also established at open surgery in 104 patients. This snapshot of ureteral trauma in a modern European setting is similar to that seen in the USA (2).

3.3 diagnosis

3.3.1 Clinical diagnosis

There are no classic clinical symptoms and signs associated with acute ureteral trauma caused by external injury (3). In view of this, the diagnosis must be one of suspicion. Ureteral trauma should be suspected in all cases of penetrating abdominal injury, especially gunshot wounds, and also in cases of blunt deceleration trauma, in which the kidney and renal pelvis can be torn away from the ureter. This deceleration injury is more likely to occur in children because of their hyperextensible vertebral column (4). Haematuria is also a poor indicator of injury, as it is present in only half of those with ureteral trauma (5).

It is possible for isolated ureteral injuries to be missed. Such patients tend to present with subsequent evidence of upper tract obstruction, urinary fistula formation and sepsis (6). After gynaecological pelvic surgery, any woman who complains of flank pain, develops vaginal leakage of urine or becomes septic should also

be suspected of having injury to the ureter or bladder and should be investigated appropriately. At surgery, when the ureter is explored to exclude injury, the use of intravenous indigo carmine or methylene blue is to

be recommended. This will help reveal the site of injury by leakage of blue-stained urine. This is especially important in partial tears.

3.3.2 radiological diagnosis

Ureteral injury may cause radiological signs of upper urinary tract obstruction but the sine qua non of ureteral injury is extravasation of radiological contrast material (3). This sign can be produced by the use of intravenous pyelography (IVP), giving 2 mg of contrast material per kilogram of body weight. However, because of

the increasing use of computed tomography (CT) scanning in polytraumatized patients, the diagnosis is increasingly made with this modality.

If a high suspicion of ureteral injury exists and the CT scan is non-diagnostic, then a ‘poor man’s IVP’can be obtained by taking a plain kidney-ureter-bladder (KUB) film 30 minutes after intravenous injection

of CT contrast medium. If this is also non-diagnostic and a suspicion of injury still exists, then retrograde pyelography should be undertaken as the gold standard investigation.

3.4 Classification

The American Association for the Surgery of Trauma has classified ureteral injuries as shown in Table 4 (7). Table 4: Classification of ureteral injury

Grade Description of injury

I Haematoma only

II Laceration < 50% of circumference

III Laceration > 50% of circumference

IV Complete tear < 2 cm of devascularization

V Complete tear > 2 cm of devascularization

3.5 Management

3.5.1 Partial injuries

These can be defined as grade I to II lesions. Once recognized, they can be managed with ureteral stenting or by placement of a nephrostomy tube to divert urine (3). There is no prospective clinical trial comparing outcomes between these techniques. We believe that ureteral stenting is probably superior because a stentacross the injury will allow secure drainage of the kidney, as well as providing canalization and stabilization of the injury. We believe that this will reduce the subsequent risk of stricture. The stent may be placed in an antegrade or retrograde fashion. In all cases, fluoroscopy and ureteropyelography with radio-opaque contrast should be used to guide stent placement.

The procedure should commence with the passage of a hydrophilic atraumatic guidewire across the damaged segment of ureter. Once across the site of the injury, an access catheter can be backloaded over the wire and passed across the injury. The hydrophilic wire can then be exchanged for a 0.038-inch wire, and the stent deployed. If this technique is utilized, a bladder catheter should be left in place for 2 days to limit stent reflux during voiding until mucosal healing has begun. The stent should be left in place for at least 3 weeks. The patient should have a follow-up dynamic renogram and IVP between 3 and 6 months, or sooner if lateralizing flank pain develops. If there is evidence of stricture, then this should be managed by endo-urological or open surgical techniques, as appropriate.

If a grade II or III injury is encountered during immediate surgical exploration of an iatrogenic injury,

then primary closure of the ureteral ends over a stent may be recommended, with placement of an external, non suction drain adjacent to the injury.

3.5.2 Complete injuries

These are grade III to V injuries. Successful repair should utilize the principles outlined in Table 5.

Table 5: Principles of repair of complete injury

• Debridement of ureteral ends to fresh tissue

• Spatulation of ureteral ends

• Placement of internal stent

• Watertight closure of reconstructed ureter with absorbable suture

• Placement of external, non-suction drain

• Isolation of injury with peritoneum or omentum

The type of reconstructive repair procedure chosen by the surgeon depends on the nature and site of the injury (3). The options are depicted in Figure 4.

figure 4: diagram of the options for repair of complete injuries, based on the site of the injury

upper third:Uretero-ureterostomy

Transuretero-ureterostomy

Ureterocalycostomy

Middle third: Uretero-ureterostomy

Transuretero-ureterostomy

Boari flap and reimplantation

lower third:Direct reimplantation

Psoas hitch

Blandy cystoplasty

Complete:Ileal interposition

Autotransplantation

3.5.3 sterile surgery

3.5.3.1 Uretero-ureterostomy

Using the principles outlined above, the ureteral ends are debrided and freshened. The ends are spatulated.An internal JJ stent is inserted and the ends are closed over the stent using an interrupted 4/0 vicryl suture. An external, non-suction drain is placed at the site of the injury, and a catheter is left in the bladder. The bladder catheter can be removed after 2 days. The wound drain can be removed 2 days later if drainage is low. The stent should be removed after 6 weeks, and a follow-up renogram and IVP should be obtained after 3 months to assess the patency of the repair.

3.5.3.2 Ureterocalycostomy

In cases were the pelvi-ureteral junction has been destroyed, the lower pole of the affected kidney can be amputated to expose the lower pole infundibulum and calyces. The distal ureteral end can then be debrided and spatulated, and anastomosed to the lower pole calyx, over an internal stent, using an interrupted 4/0 vicryl suture. An external, non-suction drain is placed at the site of the injury and a catheter is left in the bladder. The bladder catheter can be removed after 2 days. The wound drain can be removed 2 days later if drainage is low. The stent should be removed after 6 weeks and a follow-up renogram and IVP should be obtained after 3 months to assess the patency of the repair.

3.5.3.3 Transuretero-ureterostomy

The distal end of the injured ureter is ligated with an absorbable suture. The proximal end is debrided and spatulated. This end is then transposed across the midline through a retroperitoneal window above the level of the inferior mesenteric artery. A 1.5 cm ureterotomy is made on the medial aspect of the contralateral ureter.

A stent is placed from the ipsilateral kidney, through the anastomosis, and down the distal contralateral ureter into the bladder. A watertight anastomosis is fashioned using an interrupted 4/0 vicryl suture. An external, nonsuction drain is placed at the site of the injury, and a catheter is left in the bladder. The bladder catheter can be removed after 2 days. The wound drain can be removed 2 days later if drainage is low. The stent should be removed after 6 weeks, and a follow-up renogram and IVP should be obtained after 3 months to assess the patency of the repair.

3.5.3.4 Ureteroneocystostomy with Boari flap

The proximal ureteral end is debrided and spatulated. A traction suture is placed. The distal ureteral end is ligated with an absorbable suture. The bladder is filled with 200-300 ml of normal saline via a urethral catheter, and controlling stay sutures are placed on the bladder. The L-shaped flap is raised, its base being approximately four times wider than the width of the ureter to be implanted. The ureter is pulled through a submucosal tunnel in the flap and secured to the bladder mucosa using an interrupted 4/0 vicryl suture. Anchoring sutures can be placed at the serosal aspect of the ureter to secure it to the bladder. A stent is placed across the neo-ureterocystostomy, and a suprapubic catheter is placed in the bladder. The bladder

is then closed in two layers with 2/0 vicryl sutures. An external, non-suction drain should be placed at the

site of the reimplant; it can be removed after 2 days. The urethral catheter can be removed at the same time. The suprapubic catheter can be removed after a cystogram at 2 weeks, and the stent can be removed after 6 weeks. An IVP and renogram should be obtained 3 months thereafter to confirm the patency of the neocystostomy.

3.5.3.5 Ureterocystostomy and psoas hitch

The proximal ureteral end is debrided and spatulated. A traction suture is placed. The distal ureteral end is ligated with an absorbable suture. The fundus of the bladder is mobilized, and the contralateral superior vesical pedicle may be divided to improve fundal mobility. The bladder is filled with 200-300 ml of normal saline via a urethral catheter, and controlling stay sutures are placed. A cystotomy (Blandy) is performed perpendicular to the line of the ureter. Two fingers are placed inside the bladder to stretch it gently towards the ipsilateral psoas tendon. Three non-absorbable 2/0 sutures are placed between the bladder wall and the tendon, with care being taken to avoid the genitofemoral nerve.

Ureteroneocystostomy is then undertaken using either the Leadbetter-Politano or Lich-Gregoire techniques. A JJ stent is placed across the reimplant, and a suprapubic catheter is placed in the bladder. The bladder is then closed in two layers with 2/0 vicryl in the line of the ureter, thus providing extra length to the hitch. The anastomosis is thus under no tension. An external, non-suction drain should be placed at the site

of the reimplant, and can be removed after 2 days. The urethral catheter can be removed at the same time. The suprapubic catheter can be removed after a cystogram at 2 weeks, and the stent can be removed after 6 weeks. An IVP and renogram should be obtained 3 months thereafter to confirm the patency of the neocystostomy.

3.5.3.6 Ileal interposition graft

In cases of long segment ureteral destruction, the ureter can be totally replaced using the distal ileum. This should be avoided in patients with coincidental gastrointestinal disease, such as Crohn’s disease, and inpatients with impaired renal function. A 25-cm length of ileum is taken out of bowel continuity about 20 cm proximal to the ileocaecal valve. Gastrointestinal continuity is restored with an ileo-ileal anastomosis using interrupted 3/0 seromuscular vicryl. The mesenteric is repaired using 2/0 vicryl. The ileal segment is placed in the isoperistaltic orientation between the renal pelvis and the bladder. Ileo-pelvic and cysto-ileal end-to-end anastomoses are fashioned using 2/0 vicryl. A nephrostomy tube should be inserted into the ipsilateral kidney to decompress the affected upper tract. A catheter should be placed in the bladder. External, non-suction drains should cover the proximal and distal anastomoses. Lastly, the reconstruction should be wrapped in omentum.

The wound drains can be removed after 2 days. A nephrostogram should be performed after 3 weeks; if no leakage is demonstrated, the nephrostomy can be clamped and then removed. Finally, the urinary catheter can be removed. Follow-up should include IVP and renography at 3 months, together with testing for the levels of serum creatinine, chloride, bicarbonate and base excess, looking for evidence of hyperchloraemic metabolic acidosis.

3.5.3.7 Autotransplantation

If complete ureteral disruption should occur in the presence of coincidental gastrointestinal disease or impaired renal function, then autotransplantation of the affected renal unit can be undertaken. The renal artery and vein are divided long at the aorta and cava. The kidney is moved to the pelvis, and vascular continuity is restored using 5/0 prolene for the artery and 4/0 prolene for the vein. A Lich-Gregoire extravesical neoureterocystostomy can then be fashioned to re-establish urinary drainage. This need not be stented. A covering external, non-suction drain should be placed, and a catheter inserted in the bladder. The drain can be removed after 2 days, if dry, and the catheter removed after a cystogram at 2 weeks. Again, follow-up at 3 months with IVP and renogram is recommended.

3.5.3.8 Nephrectomy

There is one circumstance in which immediate nephrectomy should be undertaken. This is when ureteral injury complicates the repair of an abdominal aortic aneurysm or other vascular procedure in which a vascular prosthesis is to be implanted. We feel that immediate excision of the corrupted renal unit and its damaged ureter leads to less chance of urinary leak, urinoma, sepsis and graft infection.

3.6 referenCes

1. Dobrowolski Z, Kusionowicz J, Drewniak T, Habrat W, Lipczynski W, Jakubik P and Weglarz W. Renal

and ureteric trauma: diagnosis and management in Poland. BJU Int 2002;(7):748-51.

http://www.ncbi.nlm.nih.gov/pubmed/11966637

2. Palmer LS, Rosenbaum RR, Gershbaum MD, Kreutzer ER. Penetrating ureteral trauma at an urban

trauma center: 10-year experience. Urology 1999;54(1):34-6.

http://www.ncbi.nlm.nih.gov/pubmed/10414723

3. Armenakas NA. Ureteral trauma: surgical repair. Atlas Urol Clin North Am 1998;6:71-8

4.

4. Morey AF, Bruce JE, McAninch JW. Efficacy of radiographic imaging in pediatric blunt renal trauma.

J Urol 1996;156(6):2014-8.

http://www.ncbi.nlm.nih.gov/pubmed/11380

5. Medina D, Lavery R, Ross SE, Livingston DH. Ureteral trauma: preoperative studies neither predict

injury nor prevent missed injuries. J Am Coll Surg 1998;186(6):1-4.

http://www.ncbi.nlm.nih.gov/pubmed/9632150

6. McGinty DM, Mendez R. Traumatic ureteral injuries with delayed recognition. Urology 1997;10(2):

115-7.

http://www.ncbi.nlm.nih.gov/pubmed/8448

7. Moore EE, Cogbill TH, Jurkovitch GJ, McAninch JW, Champion HR, Gennarelli TA, Malangoni MA,

Shackford SR, Trafton PG. Organ injury scaling. III: Chest wall, abdominal vascular, ureter, bladder,

and urethra. J Trauma 1992;33(3):337-9.

http://www.ncbi.nlm.nih.gov/pubmed/1404499

4. bladder TrauMa

4.1 background

Among abdominal injuries that require surgical repair, 2% involve the bladder (1). Blunt or penetrating trauma account for 67-86% and 14-33% of bladder ruptures, respectively (2-4). Motor vehicle accidents are the

most common cause (90%) of bladder ruptureby blunt trauma is (5-7). In the setting of blunt trauma, bladder rupture may be classified as either extraperitoneal with leakage of urine limited to the perivesical space, or intraperitoneal, in which the peritoneal surface has been disrupted, with concomitant urinary extravasation.bladder trauma: facts and figures

•

70-97% of patients with bladder injuries caused by blunt trauma have associated pelvic fractures (3, 8, 9).

•

P ubic symphysis diastasis, sacroiliac diastasis, and sacral, iliac, and pubic rami fractures are significantly associated with bladder rupture, whereas isolated acetabular fractures are not (10, 11). •

> 50% of the associated pelvic fractures are of the pubic ramus (12). •

U p to 30% of patients with pelvic fractures will have some degree of bladder injury (13). •

M ajor bladder injury occurs in only 5-10% of patients who have pelvic fracture(s) (7, 14). •

> 85% of patients with pelvic fractures have associated injuries in other organ systems (8), with a mortality rate of 22-44% (12, 13, 15).

•

A pproximately 25% of intraperitoneal bladder ruptures occur in patients who do not have pelvic fracture(s) (7).

During a motor vehicle accident, traumatic forces can be transferred to the bladder by the seatbelt; injuries usually occur in patients with a full bladder. The degree of distension of the bladder with urine determines its shape and, to some degree, the injury it sustains. A fully distended bladder can be ruptured by a light blow; however, an empty bladder is seldom injured, except by crushing or penetrating wounds. Pelvic scars or pre-existing pelvic pathology can influence susceptibility to injury (16).

Combined intra- and extraperitoneal rupture may occur in 2-20% of cases (7, 17-19). Simultaneous bladder and prostate-membranous urethra ruptures occur in 10-29% of male patients (10). Several studies investigating pelvic fractures and associated injuries in paediatric patients reported a lower incidence of urogenital injury (7-14%) (20-23), than in comparative adult series (7, 13, 14). In seven paediatric series (20-26), the average rate of bladder injury in patients with pelvic fractures was 4%. Motor vehicle accidents were the cause of the trauma in 97% of cases (26).

4.1.1 iatrogenic trauma

During lower abdominal operations, the bladder is the most frequently injured genitourinary organ (27). Most iatrogenic injuries occur during:

•

o pen abdominal or pelvic surgery (85%)•

a nterior vaginal surgery (9%)•

l aparoscopy (6%).The majority (92%) of these injuries are graded as III-IV, using the American Association for the Surgery of Trauma (AAST) scale (27). Most injuries occur during obstetric and gynaecological procedures (52-61%), followed by urological (12-39%) and general surgical (9-26%) interventions (27, 28). Of the general surgical operations that result in iatrogenic injury to the bladder, most involve resection of bowel as a result of malignancy, diverticulitis or inflammatory diseases (27, 28).

Bladder injury occurs during gynaecological operations in 0.3-8.3% of cases (29-34). Concurrent anti-

incontinence surgery significantly increases the risk of injury to the bladder (13% vs 3%; P= 0.049) (34). Most cases of urological iatrogenic trauma occur during vaginal operations and laparoscopy (27, 28). The incidence of bladder wall perforation is generally low (1%) during transurethral resection of bladder tumours, and most (88%) can be managed by catheter drainage (35, 36). Transurethral resection of the prostate is also associated with low injury rates (37).

Routine cystoscopy is an important adjunct to the major gynaecological procedures, and its omission may result in underestimation of iatrogenic bladder injury. An extensive review of the literature indicated that in studies not involving routine cystoscopy, the frequency of bladder injury varied from 0.2/1000 to 19.5/1000, with an overall frequency of 2.6/1000. Only 52% of bladder injuries were identified and managed intraoperatively (31). In studies involving routine cystoscopy, the frequency of bladder injury varied from

0.0/1000 to 29.2/1000, with an overall frequency of 10.4/1000. Up to 85% of unsuspected bladder injuries were identified with the use of cystoscopy and were managed successfully intraoperatively (31). Routine cystoscopy is recommended after any type of incontinence surgery as it enables identification of unsuspected bladder injury in 85% of patients (31, 32, 34, 38).

Surgical procedures for the correction of stress urinary incontinence can also result in bladder trauma. The Edited by Foxit Reader Copyright(C) by Foxit Software Company,2005-2008For Evaluation Only.

rate of bladder injury is below 3% in Burch colposuspension (39-41). Bladder injury is the most common complication of the tension-free vaginal tape (TVT) procedure, with an incidence of 2.0-11.5% (42-47) and up to 19% in patients with prior failed incontinence surgery (48).

The transobturator tape (TOT) procedure minimizes the retropubic needle passage, and the incidence of bladder injury is expected to be low. Although during early experience with this technique rates of injury were similar to those associated with the TVT procedure (39), a recent meta-analysis indicated a lower incidence of bladder injuries (odds ratio: 0.12; 95% confidence interval: 0.05-0.33) with TOT procedures (49).

4.2 Classification Table 6: bladder injury scale 1

grade* description

I Hematoma Contusion, intramural hematoma

Laceration Partial thickness

II Laceration Extraperitoneal bladder wall laceration <2 cm

III Laceration Extraperitoneal (>2 cm) or intraperitoneal (<2 cm) bladder wall laceration IV Laceration Intraperitoneal bladder wall laceration >2 cm

V Laceration I ntraperitoneal or extraperitoneal bladder wall laceration extending into the

bladder neck or ureteral orifice (trigone)

*Advance one grade for multiple injuries up to grade III

1 Adapted from the AAST.

4.3 risk factors

Individuals who driving under the influence of alcohol are likely to have a distended bladder and a motor vehicle accident. Driving after drinking alcohol is therefore a risk factor for bladder injury (19) (level of evidence: 3).Concurrent anti-incontinence surgery during gynaecological procedures results in a fourfold increased risk of bladder injury, and is therefore a risk factor for iatrogenic bladder trauma (34) (level of evidence: 3).

4.4 diagnosis

The most common signs and symptoms in patients with major bladder injuries are gross haematuria (82%) and abdominal tenderness (62%) (3). Other findings may include inability to void, bruises over the suprapubic region and abdominal distension (6). Extravasation of urine may result in swelling in the perineum, scrotum and thighs, as well as along the anterior abdominal wall within the potential space between the transversalis fascia and the parietal peritoneum.

4.4.1 Macroscopic (gross) haematuria

Gross haematuria indicates urological trauma (level of evidence: 3). Traumatic bladder rupture is strongly correlated with the combination of pelvic fracture and gross haematuria; Morey et al. reported gross haematuria in all their patients with bladder rupture, and 85% had pelvic fractures (50). Thus, the classic combination of pelvic fracture and gross haematuria constitutes an absolute indication for immediate cystography in patients who have blunt trauma (3, 7, 13, 50) (level of evidence: 3).

The presence of gross blood at the urethral meatus is diagnostic of a urethral injury (level of evidence: 3). A Foley catheter should not be inserted before a retrograde urethrogram has been carried out to ensure urethral integrity (51). Although grossly clear urine in a trauma patient without a pelvic fracture virtually eliminates the possibility of bladder rupture, 2-10% of patients with bladder rupture may have only microhaematuria or no haematuria at all (5, 51).

In a retrospective review of more than 8000 paediatric trauma patients, of those cases with pelvic fractures, only one patient (0.5%) had an extraperitoneal bladder rupture (26). Lower urogenital injury occurred in six patients (2.8%). The absence of gross haematuria ruled out serious injury in this cohort.

Based on this data, no further work-up was recommended in paediatric patients with pelvic fractures without gross haematuria. It is recommended that patients with gross haematuria, multiple associated injuries or significant abnormalities found on physical examination should be further evaluated with retrograde urethrography and cystography (level of evidence: 3).

Edited by Foxit Reader Copyright(C) by Foxit Software Company,2005-2008For Evaluation Only.

In the trauma patient with a pelvic ring fracture, microscopic haematuria might indicate bladder laceration, and further investigation is warranted (level of evidence: 3). However, the exact quantity of blood in the urine that should trigger investigation is controversial.

• M organ et al. reported that no ruptures were seen in patients with <25 red blood cells/high-power field (rbc/hpf) (10).

• W erkman et al. (52) concluded that if cystography had been restricted to patients with > 35-50 rbc/ hpf, no perforation would have been missed in their series.

• F uhrman et al. (53) believe that cystography in blunt trauma should be restricted to patients with gross haematuria, which they defined as > 200 rbc/hpf. They also thought that a retrograde urethrogram

should be carried out first.

Existing data do not support lower urinary tract imaging in all patients with pelvic fracture or microscopic haematuria alone. Hochberg and Stone (54) concluded that cystography might be safely reserved for those patients with pelvic fracture considered to be high risk for bladder injury (significant pubic arch involvement, gross haematuria and/or haemodynamic instability), as 90% of patients in their series with pelvic fracture did not have a bladder rupture.

These observations do not appear to be valid for paediatric trauma patients. Abou-Jaoude et al. (55) reported a threshold for radiological evaluation of ≥ 20 rbc/hpf would miss 25% of cases with bladder injury. In contrast with other reported series (26), they suggested that lower urogenital tract evaluation in paediatric trauma patients, especially in the presence of pelvic fractures, should be based as much on clinical judgment as on the presence of haematuria (55) (level of evidence: 3).

4.4.3 Cystography

Retrograde cystography is the standard diagnostic procedure in the evaluation of bladder trauma (7, 13, 56-58) (level of evidence: 3). This is the most accurate radiological study to identify bladder rupture. When adequate bladder filling and post-void images are obtained, cystography has an accuracy rate of 85-100% (5, 7, 59, 60). Bladder rupture is usually diagnosed when the contrast is identified outside the bladder. Adequate distension of the urinary bladder is crucial to demonstrating perforation, especially in cases of penetrating trauma, as most instances of a false-negative retrograde cystography were found in this situation (56).

Cystography requires plain film, filled film, and post-drainage films (as a minimum) (level of evidence: 3); half-filled film and obliques are optional. For the highest diagnostic accuracy, the bladder must be distended using instillation of at least 350 mL of contrast medium by gravity. Bladder injury may be identified only on the post-drainage film in approximately 10% of cases (7). False-negative findings may result from incorrectly performed studies with less than 250 mL of contrast instillation or omission of a post-drainage film (61) (level of evidence:

3). Only a correctly performed cystography should be used to exclude bladder injury (7).

4.4.4 excretory urography (intravenous pyelogram)

An intravenous pyelogram (IVP) is inadequate for evaluation of the bladder and urethra after trauma, not only because of dilution of the contrast material within the bladder, but also because resting intravesical pressure

is simply too low to demonstrate a small tear (16, 62). An IVP has a low accuracy (15-25%) (15) , and clinical studies have indicated that IVP has an unacceptably high false-negative rate (-84%), which precludes its use as a diagnostic tool in bladder injuries (52, 59, 63) (level of evidence: 3).

4.4.5 ultrasound (us)

Although, the use of US in bladder rupture has been described (), it is not routine for evaluation of

bladder injury. Free peritoneal fluid in the presence of normal viscera, or failure to visualize the bladder after transurethral saline instillation, are highly suggestive of bladder rupture (66) (level of evidence: 3). Practically, however, US is not definitive in bladder or urethral trauma and is almost never used.

4.4.6 Computed tomography (CT)

CT is clearly the method of choice for the evaluation of patients with blunt or penetrating abdominal and/or pelvic trauma (level of evidence: 3). However, routine CT is not reliable in the diagnosis of bladder rupture, even if an inserted urethral catheter is clamped. CT demonstrates intraperitoneal and extraperitoneal fluid, but cannot differentiate urine from ascites.

As with IVP, the bladder is usually inadequately distended to reveal extravasation through a bladder laceration or perforation during routine abdominal and pelvic studies. Thus, a negative study cannot be entirely trusted,and routine CT cannot exclude bladder injury (12, 16, 65).

In a review of the cystograms and CT scans (CT cystography) of 25 patients who underwent both investigations during the initial evaluation of blunt abdominal trauma, five patients were found to have bladder rupture, three of which were extraperitoneal and two intraperitoneal (66); all of the injuries were detected by both studies.

It was concluded that delayed imaging or contrast instillation could provide the adequate bladder distention needed to demonstrate contrast extravasation from the injury site. Similarly, in a series of 316 patients, 44 cases were diagnosed with bladder ruptures (60). In patients who underwent a formal surgical repair, 82% had operative findings that exactly matched the CT cystography interpretation. Either retrograde cystography or CT cystography are diagnostic procedures of choice for suspected bladder injury (51).

CT cystography can be used in place of conventional cystography (overall sensitivity 95% and specificity 100%) (level of evidence: 3), especially in patients undergoing CT scanning for other associated injuries (60). However, this procedure should be performed using retrograde filling of the bladder with a minimum of 350 mL of dilute contrast material (7, 66, 67).

In conclusion, CT cystographic features may lead to accurate classification of bladder injury and allow prompt, effective treatment without further radiation exposure and the additional cost of conventional cystography (70) (level of evidence: 3).

4.4.7 angiography

Angiography is seldom, if ever, indicated. It can be useful in identifying an occult source of bleeding and can guide its subsequent therapeutic embolization (16).

4.4.8 Magnetic resonance imaging (Mri)

It is extremely difficult to monitor a seriously injured patient in a strong magnetic field; MRI therefore has little place in the evaluation of acute bladder (16). The use of MRI has been described for later evaluation of urethral injury (69-71).

4.4.9 Cystoscopy

Mainly useful in iatrogenic trauma, routine cystoscopy identifies 85% of the unsuspected injuries to the bladder that would otherwise go unnoticed (31, 34, 39). Thus, it must be use as an adjunct to major gynaecological operations as well as surgical interventions for incontinence (level of evidence: 3).

4.5 Treatment

The first priority in the treatment of bladder injuries is stabilization of the patient and treatment of associated life-threatening injuries (level of evidence: 3).

4.5.1 blunt trauma: extraperitoneal rupture

Most patients with extraperitoneal rupture can be managed safely by catheter drainage alone, even in the presence of extensive retroperitoneal or scrotal extravasation (61) (level of evidence: 3). Obstruction of the catheter by clots or tissue debris must be prevented for healing to occur. A success rate of ğ90% was reported with this approach in extraperitoneal rupture (5): 87% of the ruptures were healed in 10 days, and virtually all were healed in 3 weeks (57). However, bladder neck involvement (2), the presence of bone fragments in the bladder wall, or entrapment of the bladder wall will necessitate surgical intervention (19) (level of evidence: 3). 4.5.2 blunt trauma: intraperitoneal rupture

Intraperitoneal ruptures occurring after blunt trauma should always be managed by surgical exploration (level of evidence: 3). This type of injury involves a high degree of force and, because of the severity of associated injuries, carries a high mortality (20-40%) ((72). Lacerations are usually large in these cases, with the potential risk of peritonitis due to urine leakage if left untreated (61). Abdominal organs should be inspected for possible associated injuries, and urinoma must be drained, if present.

4.5.3 Penetrating injuries

All bladder perforations resulting from penetrating trauma should undergo emergency exploration and repair (61) (level of evidence: 3).

4.5.4. iatrogenic injuries

Iatrogenic bladder perforations can occur during any pelvic, abdominal, or vaginal procedure (27). Prompt intraoperative recognition is extremely important to ensure a successful repair. Generally, suture repair is

satisfactory, limiting unnecessary extravesical dissection (level of evidence: 3). Most (> 95%) of urinary bladder injuries sustained during gynaecological operations are detected and can be managed during surgery (73). Repair can be performed either transvaginally or abdominally. Simple catheter drainage is sufficient in most cases of bladder perforation during transurethral resection of prostate or bladder tumours (36-38) (level of evidence: 3).

4.6 recommendations

4.7

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5. ureTHral TrauMa

5.1 anatomical and aetiological considerations

The male urethra is divided into the anterior and posterior sections by the urogenital diaphragm. The posterior urethra consists of the prostatic and the membranous urethra. The anterior urethra consists of the bulbar and penile urethra. Only the posterior urethra exists in the female; the anterior urethra corresponds to the labia minora, which results from persistent separation of the urethral folds on the ventral surfaces of the genital tubercle.

5.1.1 Posterior urethral injuries

Road traffic accidents, falls, and crush injuries can cause pelvic fractures, which result in injuries to the posterior urethra. About two-thirds (70%) of pelvic fractures occur because of motor vehicle accidents.

The incidence of pelvic fracture is 20% in survivors of motor accidents where fatalities have occurred. The incidence is nearly 50% in fatal pedestrian accidents. Twenty-five per cent of cases result from a fall from a height (1, 2).

Altogether, blunt trauma accounts for more than 90% of urethral injuries (3). Overall, the male posterior urethra is injured in 4-19% and the female urethra in 0-6% of all pelvic fractures (2, 4-12). The female urethra is rarely injured, except by contusion or laceration by bone fragments.

During crush or deceleration impact injury, the severe shearing forces necessary to fracture the pelvis are transmitted to the prostatomembranous junction, resulting in disruption of the prostate from its connection to the anterior urethra at the prostatic apex. Retrograde urethrography and magnetic resonance imaging (MRI) correlates to this location of the injury (13, 14). Cadaveric studies suggest that in most cases the membranous urethra is torn distally to the urogenital diaphragm (15).

An accurate knowledge of the functional anatomy of the sphincter mechanism is essential to the success

of posterior urethral surgery. Continence after anastomotic reconstruction of subprostatic pelvic fracture urethral distraction defects depends upon the function of the bladder neck and of the distal urethral sphincter mechanism, each of which is competent and independently capable of maintaining continence in the absence of the other (16).

Unstable pelvic fractures (8, 11, 17-21), bilateral ischiopubic rami fractures (‘straddle fracture’), and symphysis pubis diastasis have the highest likelihood of injuring the posterior urethra. In particular, the combination ofstraddle fractures with diastasis of the sacroiliac joint has the highest risk of urethral injury; the odds ratio is about 7 times higher than for either straddle injuries or sacroiliac (‘Malgaigne’) fractures alone (Table 7) (2). Table 7: odds ratio of suffering urethral injury with different types of pelvic fracture

Type of fracture odds ratio

Single ramus 0.6

Ipsilateral rami 0.8

Malgaigne’s (vertical shear) 3.4

Straddle 3.9

Straddle plus sacroiliac 24.0

Lower urinary tract injury has been reported in about 16% of patients with unilateral rami fractures and in 41% of patients with bilateral rami fractures (22). Anteroposterior compression injuries from frontal crushes produce more severe pelvic fractures, major retroperitoneal bleeding and more frequent injury to the lower urinary tract than do lateral crashes (23).

Prostatomembranous urethral injuries can vary from simple stretching (25%) to partial rupture (25%) or complete disruptions (50%) (2). The more severe injuries result in prostatourethral displacement, with progressive scar formation encompassing the rupture defect. The incidence of double injuries involving

the urethra and the bladder ranges between 10% and 20% in males, and may be intraperitoneal (17-39%), extraperitoneal (56-78%), or both (2, 7).

Urethral injuries, by themselves, are never life-threatening, except as a consequence of their close association with pelvic fractures and multiple organ injuries, which occur in about 27% of cases. Initially, the assessment and management of other associated injuries is usually more important than the assessment and management of the urethral injury (24).

The American Association for Surgery of Trauma (AAST) has proposed the classification given in Table 8. Table 8: organ injury scaling iii classification of urethral injuries (25)

grade description appearance

I Contusion Blood at the urethral meatus;

Normal urethrogram

II Stretch injury Elongation of the urethra without extravasation on urethrography

III Partial disruption E xtravasation of contrast at injury site with contrast visualised in the

bladder

IV Complete disruption E xtravasation of contrast at injury site without visualisation in the

bladder;

< 2 cm of urethral separation

V Complete disruption C omplete transection with > 2 cm urethral separation or extension into

the prostate or vagina

New classifications provide an anatomical classification and a means of comparing treatment strategies and outcomes (26, 27). The classification shown in Table 9 combines the best of previous classifications and has direct implications in clinical management.

Table 9: Classification of blunt anterior and posterior urethra

grade description appearance

I Stretch injury Elongation of the urethra without extravasation on urethrography

II Contusion Blood at the urethral meatus

No extravasation on urethrography

III Partial disruption of Extravasation of contrast at injury site with contrast visualised in anterior or posterior the proximal urethra or bladder

urethra

IV Complete disruption Extravasation of contrast at injury site without visualisation of proximal of anterior urethra urethral or bladder

V Complete disruption Extravasation of contrast at injury site without visualisation of bladder of posterior urethraVI Complete or partial

disruption of posterior

urethra with associated

tear of the bladder neck

or vagina

Clinical management is according to the injury grade:

• grade I no treatment required

• g rades II and III can be managed conservatively with suprapubic cystostomy or urethral catheterisation

• grades IV and V will require open or endoscopic treatment, primary or delayed

• grade VI requires primary open repair.

5.1.1.1 Urethral injuries in children

Urethral injuries in children are similar to those in adults. The only significant difference is that straddle pelvic fractures, Malgaigne’s fractures or the association of straddle plus sacroiliac joint fracture is more common in children than in adults. In addition, posterior urethral injuries can involve the prostatic urethra and the bladder neck, as well as the membranous urethra. The tear is often in the prostatic urethra or at the bladder neck because of the rudimentary nature of the prostate, and is more likely to be a complete rupture (69% versus 42%). Urethral stretching is less common than in adults. The more proximal the injury, the greater the risk of incontinence, impotence and stricture (2, 24, 28, 29).

5.1.1.2 Urethral injuries in women

These are rare events since the female urethra is short and mobile, without any significant attachments to the pubic bone. They usually occur in children. They are often accompanied by severe pelvic fractures, where bony fragments of the fractured pelvis can lacerate the urethra. Urethral injuries in females frequently extend into the bladder neck or vagina, and often disrupt the normal continence mechanism (4, 12). Injury to the female urethra is usually a partial tear of the anterior wall and is rarely a complete disruption of the proximal or distal urethra (29).

5.1.1.3 Penetrating injuries to the perineum

These can occur after external violence such as gunshot or stab wounds, or as iatrogenic injuries caused by endoscopic instruments or during surgery for vaginal repair. In developing countries, urethral and bladder neck damage occur quite often as a result of ischaemic injury during obstructed labour.

5.1.2 anterior urethral injuries

Anterior urethral injuries result from blunt trauma more frequently than from penetrating trauma (Table 10). Table 10: aetiology of anterior urethral injuries

Cause Example

Blunt trauma • Vehicular accidents

• Fall astride (straddle)

• Kicks in the perineum

• Blows in the perineum from bicycle handlebars, tops of fences, etc.

Sexual intercourse • Penile fractures

• Urethral intraluminal stimulation

Penetrating trauma • Gunshot wounds

• Stab wounds

• Dog bites

• External impalement

• Penile amputations

Constriction bands • Paraplegia

Iatrogenic injuries • Endoscopic instruments

• Urethral catheters/dilators

5.1.2.1 Blunt trauma

Vehicular accidents, falls or blows cause most anterior urethral injuries. In contrast to posterior urethral trauma, they are rarely associated with pelvic fractures. They are usually straddle-type injuries caused by blows of blunt objects against the perineum, such as bicycle handlebars or the top of a fence. In this type of accident, therelatively immobile bulbar urethra is trapped and compressed by a direct force on it against the inferior surface of the symphysis pubis. These injuries are more common in children than in adults (28).

5.1.2.2 Intercourse-related trauma

A less common cause of blunt anterior urethral trauma is penile fracture. This rupture of the corpus cavernosum usually occurs during intercourse. In these injuries, the urethra is involved in 20% of the cases (30). Intraluminal stimulation of the urethra with foreign objects has also been reported to cause anterior urethral trauma. Most are short and incomplete, and occur in the distal penile urethra.

Surgery is rarely indicated and depends on the degree and extent of injury to the urethra.

5.1.2.3 Penetrating trauma

Penetrating injuries to the anterior urethra usually result from gunshot wounds and involve the pendulous

and bulbar urethral segments equally. These injuries are associated with penile and testicular injury. These can involve the rectum, which may result in pelvic abscesses and the formation of fistulae (31, 32). Other less frequent causes of external anterior urethral injuries include stab wounds, penile amputation and impalement.

5.1.2.4 Constriction band-related trauma

Individuals with paraplegia who use a constriction device for urinary incontinence and forget to release the band because of the lack of sensation can cause severe ischaemic injuries involving the penis and urethra.

5. 1.2.5 Iatrogenic trauma

Iatrogenic urethral injuries caused by instruments are by far the most common cause of urethral trauma. Urethral ischaemic injuries related to cardiac bypass procedures are not infrequent and can result in long and fibrotic strictures. A separate section in this chapter discusses iatrognic trauma in more detail (see section 4.6).

5.2 diagnosis: initial emergency assessment

5.2.1 Clinical assessment

The initial management of urethral injury is resuscitation of the patient. In the absence of blood at the meatus or genital haematoma, a urological injury is very unlikely and is excluded by catheterisation. Maintain airway and respiratory function, secure the cervical spine if necessary, and address blood loss if present. This is particularly important in posterior urethral injuries because of their close association with pelvic fractures.

The next step includes taking a complete history and carrying out physical, laboratory and radiographic evaluations in order to identify all injuries accurately. A diagnosis of acute urethral trauma should be suspected from the history. A pelvic fracture, or any external penile or perineal trauma, can be suggestive of urethral trauma (33, 34).

For penetrating injuries, the type of weapon used, including the calibre of the bullet, is helpful in assessing potential tissue damage. In a conscious patient, a thorough voiding history should be obtained to establish the time of last urination, the force of the urinary stream, whether urination is painful and whether haematuria is present. The following clinical indicators of acute urethral trauma warrant a complete urethral evaluation.

5.2.1.1 Blood at the meatus

This is present in 37-93% of patients with posterior urethral injury, and in at least 75% of patients with anterior urethral trauma (35, 36). When blood is present at the urethral meatus, do not attempt urethral instrumentation until the entire urethra is imaged. In an unstable patient, attempt to pass a urethral catheter, but if there is any difficulty, place a suprapubic catheter and perform a retrograde urethrogram when appropriate.

It is extremely unlikely that gentle passage of a urethral catheter will do any additional damage (37, 38), although it has been suggested that this may convert a partial tear into one that is complete (39). There are no convincing data indicating a higher rate of infection or urethral stricture after a single attempt at catheterisation (3). Indeed, if a urethral injury is suspected, urethrography prior to attempted catheterisation is the most prudent approach.

5.2.1.2 Blood at the vaginal introitus

This is present in more than 80% of female patients with pelvic fractures and co-existing urethral injuries (4). 5.2.1.3 Haematuria

Although non-specific, haematuria on a first-voided specimen may indicate urethral injury. The amount ofurethral bleeding correlates poorly with the severity of the injury, as a mucosal contusion or small partial tear may be accompanied by copious bleeding, while total transection of the urethra may result in little bleeding (40).

5.2.1.4 Pain on urination or inability to void

The inability to void suggests urethral disruption.

5.2.1.5 Haematoma or swelling

With anterior urethral trauma, the pattern of the haematoma can be useful in identifying the anatomical boundaries violated by the injury. Extravasation of blood or urine in a sleeve distribution along the penile

shaft indicates that the injury is confined by Buck’s fascia. Disruption of Buck’s fascia results in a pattern

of extravasation limited only by Colles’ fascia, and can extend to the coracoclavicular fascia superiorly and

the fascia lata inferiorly. This results in a characteristic butterfly pattern of bruising in the perineum. In female patients with severe pelvic fractures, the presence of labial swelling may be an indicator of urethral injury. It can be caused by urinary extravasation and warrants immediate attention.

5.2.1.6 High-riding prostate

This is a relatively unreliable finding in the acute phase since the pelvic haematoma associated with pelvic fractures often precludes the adequate palpation of a small prostate, particularly in younger men (3). A boggy mass is usually palpated without recognition of a prostate gland (41). Rectal examination is more important

as a tool to screen for rectal injuries, which can be associated with pelvic fractures. Blood on the examination finger is suggestive of a rectal injury. Assessment of concomitant genital injuries is mandatory in every case of external urethral trauma.

5.2.2 radiographic examination

Retrograde urethrography is the gold standard for evaluating urethral injury (5, 29). A scout film should be performed first to assess the radiographic technique, and to detect pelvic fractures and foreign bodies, such as bullets. This is performed using a Foley catheter in the fossa navicularis, with the balloon inflated using 1-2 mL of saline to occlude the urethra. Then, 20-30 mL of contrast material is injected while films are taken in a 30° oblique position. When severe pelvic fractures and associated patient discomfort are present, the oblique position may not always be possible. The radiographic appearance of the urethra permits classification of the injury and facilitates the subsequent management.

If posterior urethral injury is suspected, a suprapubic catheter is inserted. Later on, a simultaneous cystogram and ascending urethrogram can be carried out to assess the site, severity and length of the urethral injury. This is usually done after 3 months if a delayed repair is considered.

When the proximal urethra is not visualised in a simultaneous cystogram and urethrogram, either MRI of the posterior urethra (42) or endoscopy through the suprapubic tract is used to define the anatomy of the posterior urethra. Since manipulation in the bladder can cause the bladder neck to open and give the false impression

of incompetence, the endoscopic appearance of the bladder neck should be noted immediately on placing the scope into the bladder (43).

After assessing the endoscopic appearance of the bladder neck, the flexible endoscope can be advanced through the bladder neck into the posterior urethra to the level of obstruction. If there is a question about the length of the distraction, a simultaneous retrograde urethrogram can be performed while the endoscope is

in the posterior urethra. The radiographic appearance of the bladder neck is important, but is not as reliable

an indicator of continence as the endoscopic appearance is. Furthermore, there are patients who, despite evidence of an open or scarred bladder neck, will have acceptable continence after reconstruction. For this reason, the need for concomitant bladder neck surgery at the time of urethral reconstruction is debatable (43, 44).

Ultrasonography is not a routine investigation in the initial assessment of urethral injuries but can be very useful in determining the position of pelvic haematomas, or the exact location of the bladder when a suprapubic catheter is indicated.

Computed tomography and MRI have no place in the initial assessment of urethral injuries. However, they are useful in defining distorted pelvic anatomy after severe injury and assessing associated injuries of penile crura, bladder, kidneys and intra-abdominal organs (14, 45).

5.2.3 endoscopic examination

Urethroscopy does not have any role in the initial diagnosis of urethral trauma in males. In females, however, where the short urethra precludes adequate retrograde urethrography, urethroscopy is an important adjunct to the physical examination for the identification and staging of urethral injuries (46).

5.3 Management

The management of urethral injuries remains controversial because of the variety of injury patterns, associated injuries and treatment options available. In addition, urethral injuries are relatively uncommon, hence the limited experience of most urologists worldwide and the absence of randomised prospective studies.

5.3.1 anterior urethral injuries

5.3.1.1 Blunt injuries

Partial tears can be managed with a suprapubic catheter or with urethral catheterisation (29, 37, 47). Suprapubic cystostomy has the advantage that it not only diverts the urine away from the site of injury, but also avoids urethral manipulation (48), as well as allowing for a simultaneous study to be carried out at a later date.

If the bladder is not easily palpable suprapubically, transabdominal sonography should be used to guide the placement of the catheter. The cystostomy tube is maintained for approximately 4 weeks to allow urethral healing. Voiding cystourethrography is then performed. Remove the suprapubic tube if normal voiding can be re-established and neither contrast extravasation nor stricture is present.

The potential early complications of acute urethral injuries include strictures and infections.

Extravasated blood or urine from the urethral tear produces an inflammatory reaction that can progress to the formation of an abscess. The extent of the infection depends on the fascial planes violated (see section 4.2). The potential sequelae of these infections include urethrocutaneous fistulae, peri-urethral diverticulae and, rarely, necrotising fasciitis. Prompt urinary diversion coupled with the appropriate administration of antibiotics decreases the incidence of these complications.

After the patient has adequately recovered from any associated injuries, and the urethral injury has stabilised, the urethra can be thoroughly re-evaluated radiographically. When necessary, the appropriate reconstructive procedure is planned.

Blunt anterior urethral injuries are associated with spongiosal contusion, which makes it more difficult to evaluate the limits of urethral debridement in the acute phase. Acute or early urethroplasty is therefore not indicated, and the best management is simply suprapubic diversion.

Satisfactory urethral luminal recanalisation occurs in approximately 50% of partial anterior urethral disruptions (47, 49). Short and flimsy strictures are managed with optical urethrotomy or urethral dilatation. Denser strictures require formal urethral reconstruction. Anastomotic urethroplasty is indicated in strictures of less than 1 cm in length.

Longer strictures of the anterior urethra should not be repaired by an end-to-end anastomosis, in order to avoid chordee. In these cases, flap urethroplasty is indicated. Almost all complete ruptures of the anterior urethra require anastomotic or patch urethroplasty at 3-6 months. The only exception to this is urethral injury associated with penile fracture; this usually results in partial urethral disruption and can be repaired at the time of cavernosal closure.

5.3.1.2 Open injuries

5.3.1.2.1 Male urethral injuries

Stab wounds, gunshot wounds and dog bites to the urethra often involve the penis and testes and often require immediate exploration. During surgery, the urethral injury can be surgically evaluated and repaired as needed. Urethral strictures form in fewer than 15% of these patients (50).

Primary urethral suturing involves direct visualisation of the severed urethral ends and creation of a watertight, tension-free repair. The patient should be in a supine position. Use a circumferential subcoronal incision to deglove the penis.

In complete disruptions, the corpus spongiosum is mobilised at the level of the injury and the urethral ends dissected distally and proximally. Urethral ends are spatulated, and end-to-end anastomosis is fashioned over UPDATE MARCH 2009 49a 14 French Foley catheter. Suture small lacerations with fine absorbable material. Careful overclosure of the corpus spongiosum and skin prevents the subsequent formation of fistulae (24). Keep urethral debridement to a minimum since the spongiosum is well vascularised and will usually heal well.

As with any surgery, give pre-operative antimicrobial prophylaxis. Some experts recommend the post-operative continuation of prophylactic antibiotics, but we are not aware of any data that prove that they help. After

10-14 days, obtain a peri-catheter retrograde urethrogram with the urethral catheter in situ. Provided there is no leakage at the anastomotic site, remove the urethral catheter. If there is leakage, leave the catheter in and repeat the cystourethrogram 1 week later.

If the urethra is so extensively disrupted that primary anastomosis is not feasible, then primary repair should be aborted. This occurs with defects of more than 1-1.5 cm in length. One should marsupialise the urethra preparatory to a two-stage urethral repair, and consider a suprapubic urinary diversion. Perform a delayed elective procedure a minimum of 3 months after injury. There is no role for acute placement of a graft or flap in the initial management of any urethral injury, since contamination or decreased blood supply can compromise such a repair (33).

5.3.1.2.2 Female urethral injuries

Most female urethral disruptions can be sutured primarily. These injuries often occur together with bladder ruptures. Frequently, if the bladder injury is going to be repaired primarily, the urethral disruption can be repaired at the same time. For proximal urethral injuries, urethral exposure is best obtained transvesically. Distal urethral injuries can be approached vaginally (29). Early repair of post-traumatic urethral fistulae can also be accomplished transvaginally (4, 12).

5.3.2 Posterior urethral injuries

It is important to distinguish between inflammatory or iatrogenic posterior urethral strictures and true pelvic fracture urethral distraction defects as the principles of their surgical management are entirely different. Urethral stricture indicates a narrowing of the urethral lumen. In urethral distraction defects, there is a gap between the two otherwise normal ends of the urethra. The dismembered ends of the urethra retract, and the space between them fills with fibrous tissue. There is no urethral wall in the scarred space, and any lumen represents merely a fistulous tract between the urethral stumps. A further difference between inflammatory strictures and distraction defects is that the urethral stumps are usually not fibrotic and can be re-anastomosed without tension after distraction injury. Once anastomosed, they usually heal without stricture (51).

Erectile dysfunction occurs in 20-60% of patients after traumatic posterior urethral rupture (51-55). The most important determining factor associated with impotence is the severity of the initial injury. The incidence of erectile dysfunction being caused by the open surgical repair itself is 5% or less (51, 56). Erectile dysfunction seems to be a direct result of the pelvic fracture plus urethral injury. King reported an incidence of 42% in cases of pelvic fracture and urethral injury, but only 5% when the urethra was not injured (53). Barbagli et al. reported an incidence of 60% in patients with posterior urethral injury, compared with 14% in patients with bulbar injury (57).

Factors that correlate with the development of impotence are age, defect length and the type of fracture. Bilateral pubic rami fractures are the most frequent cause of impotence. Impotence is most commonly neurogenic, due to bilateral damage of the cavernous nerves at the prostatomembranous urethra behind the symphysis pubis (58, 59). Associated vasculogenic erectile failure may occur in up to 80% of cases (60). Dixon et al. presented evidence that impotence may also be a consequence of avulsion of the corporus cavernosum from the ischium (14). In this series, five out of six patients with avulsion of the corporus cavernosum off the inferior pubic ramus, were impotent. Spontaneous return of potency may occur up to 2 years after injury (42). Gibson reported an incidence of improved sexual function after 18 months in 21% of patients (52).

5.3.2.1 Partial urethral rupture

Manage partial tears of the posterior urethra with a suprapubic or urethral catheter. Perform urethrography at 2-weekly intervals until healing has occurred (29, 37). They may heal without significant scarring or obstruction if managed by diversion alone (48,61). Manage residual or subsequent stricture with urethral dilatation or optical urethrotomy if short and flimsy, and with anastomotic urethroplasty if dense or long (24, 37).

5.3.2.2 Complete urethral rupture

Acute treatment options include:

• primary endoscopic realignment or

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