Renal Trauma

Management
Current management of renal injuries has shifted towards a non-operative approach with up to
85% of blunt renal injuries managed nonoperatively.4 Goals of either a conservative or surgical
approach should focus on preservation of renal tissue and kidney function while minimizing the
morbidity and mortality of the injury to the child. Conservative management is appropriate for
lower grades of renal injury (I-III) and commonly involves bed rest until hematocrit
measurements have stabilized and hematuria has resolved. Monitoring of vital signs is
imperative to assess hemodynamic stability. Following discharge, limited activity should be
recommended for 2 to 6 weeks according to the clinicians impression.

This approach has proven to be highly successful in avoiding long-term complications such as
hypertension, loss of renal function and hydronephrosis. Re-evaluation with ultrasound can
reliably detect an expanding urinoma or hematoma. Patients that decline clinically or are
unstable may require additional CT imaging and possible intervention such as exploration with
an attempt at renal repair, placement of a ureteral stent or angiographic embolization.
The management of severe renal injury (grades IV-V) is more controversial and requires an
individualized approach. A significant consideration is that surgical intervention may lead to
nephrectomy rates over 85%. Patients who are hemodynamically stable with isolated high-grade
renal injuries are candidates for non-operative management.

Nonetheless, surgery is indicated for patients with a vascular pedicle injury or shattered kidney
that place the patient at risk for life-threatening hemorrhage. Absolute indications for operative
intervention also include an expanding or pulsatile retroperitoneal hematoma and the inability to
stop hemorrhage by selective angioembolization. Relative indications for exploration are
significant urinary extravasation, non-viable renal tissue, arterial injury and expanding hematoma
or if accurate staging is non-possible. Surgical management should first focus on control of the
renal pedicle and aorta. When hemostasis is achieved, inspection of the kidney and collecting
system can be performed. Devitalized tissue should be debrided and any defects in the
parenchyma closed and covered if possible. Partial nephrectomy to preserve viable parenchyma
is the operation of choice. Urinary extravasation can be managed with a ureteral stent or
nephrostomy tube. A successful outcome for emergency repair of a severe pedicle injury or
thrombosis is unlikely given the amount of warm ischemia the injured kidney will undergo
during the evaluation and resuscitation of the patient. Attempts at salvage in these situations
should be limited to extreme circumstances such as a solitary kidney or bilateral renal injuries.

Ureteral Injury
Management
The timing and specific intervention for ureteral injury depend on factors such as the
timing of diagnosis, the severity of injury and the patients overall condition. Repair principals
are similar to that of adult ureteral injury. Early recognition of an injury, such as an
intraoperative iatrogenic injury, should prompt immediate repair. Key features of an appropriate
ureteral repair consist of a tension free, spatulated anastomosis. Devitalized segments should be
excised to reapproximate healthy edges. Repair over a ureteral stent may prevent transient
obstruction from edema or hematoma and aid the healing process. In cases where direct
reanastamosis is not possible, options include further mobilization of the kidney and ureter, psoas
hitch or Boari flap with or without ureteral reimplantation, and transuretero-ureterostomy. These
considerations may be dictated by the location and extent of the injury. Nephrectomy can be
avoided even for the longest ureteral insults by ileal transposition.
Delayed recognition of ureteral injuries is common and presents a more complex management
problem. If the injury is recognized within 5-7 days, surgical intervention remains an option. If
outside of this window, reconstruction should be delayed several months. Temporary diversion
with a nephrostomy tube or internal stenting can bridge this gap or be used in an unstable patient
unfit for surgery. Conservative initial management may allow the injury to heal without need for
surgical intervention. In a series of 46 patients with ureteral injuries treated with nephrostomy,
44% of those patients needed no other treatment.

Management: Extraperitoneal vs Intraperitoneal Bladder Injury

The primary clinical distinction in bladder injury is determining an intraperitoneal vs
extraperitoneal injury site. Intraperitoneal rupture accounts for approximately 1/3 of cases.
Children with intraperitoneal rupture may develop hyponatremia, hypokalemia, and elevated
serum urea and creatinine. Intraperitoneal rupture is less common and typically occurs at the
dome of the bladder. While intraperitoneal rupture is generally an indication for operative
intervention, this decision is somewhat controversial in children. Successful nonoperative
management may be reasonable for small, isolated injuries , This decision may be an option for
stable patients with small injuries who can be observed carefully. Laparotomy for other
associated injuries is an opportunity to inspect the bladder and repair any injuries.
Extraperitoneal rupture is more commonly associated with pelvic fracture, but this is rare and
may occur in less than 1% of cases. This incidence is significantly lower in children, which is
attributed to more elastic pelvic attachments. The vast majority of extraperitoneal injuries can be
managed by catheter drainage alone. If gross hematuria persists or worsens during this period,
open repair can be considered. Furthermore, the presence of a bony spicule necessitates operative
intervention.
Conservative management should be similar regardless of the injury site. Continuous bladder
drainage is typically continued for 10-14 days in cases of conservative management and 7-10
days following operative repair. Confirmation of adequate healing can be confirmed by a
negative cystogram prior to catheter removal.

Management: Urethral Injury

Management strategies of urethral injury are largely dependent on the anatomic location. The
most important acute goals are minimizing infectious complications with broad-spectrum
antibiotics, assessing the competence of the bladder neck, and establishing urinary drainage. The
management of bulbous or anterior urethral injuries is typically simple and involves either
observation or urethral catheter drainage alone. These patients typically follow a course of
transient dysuria and hematuria and the issue resolves with conservative management. The
primary risk may be the eventual development of urethral stricture.
The initial management of posterior urethral injuries is more complex. If possible, placement of
a urethral catheter helps alignment and provides bladder drainage. In cases of complete
disruption and urethral disassociation, urethral catheter placement may not be possible.
Appropriate management in this scenario remains controversial, with accepted options including
immediate primary realignment of the urethra or suprapubic drainage and delayed
reconstruction. It is now generally accepted that the ultimate course is a result of the initial
trauma itself, rather than the repair strategy. If a delayed repair strategy is employed, continuous
drainage should be employed at least 6-8 weeks before urethroplasty. A retrograde urethrogram
can be performed before repair to aid in surgical planning. If a suprapubic catheter is available, a
cystogram maybe concurrently performed to more accurately determine the stricture length or
defect between disrupted urethral ends. Any subsequent recurrent strictures are likely to be
milder in severity and likely to respond to dilation or endoscopic urethrotomy.64-66 Repair of
recurrent strictures should be delayed for 4-6 months to allow for optimal neovascularization.

Penile Injury
Management
Superficial contusions and lacerations can typically be managed with topical antibiotic
ointments, but may require minor debridement and skin approximation depending on the
mechanism, patient anxiety level, and severity of injury.81 Empiric antibiotics may be
prescribed to decrease the risk of cellulitis, although there is little data to support this practice. If
significant penile skin is lost due to neonatal circumcision, full thickness skin grafting of the
excised prepuce or shaft skin may be performed in the immediate post-injury period. The
majority of cases can be managed by healing through secondary and antibiotic ointment,
although this strategy may involve frequent, painful dressing changes.
Zipper injuries to the penis more commonly occur in uncircumcised boys and may be
treated with mineral oil to slip the trapped skin from the zipper80 or by cutting of the median bar
of the zipper with bone cutters. In cases where conservative measures are inadequate, operative
intervention may be necessary. Devitalized skin should be excised with primary
reapproximation or healing by secondary intention in cases of delayed presentation or concern
for contamination. However, most procedures may be performed in the emergency room under
local anesthesia. The use of a benzodiazepine such as midazolam may facilitate examination.
Formal conscious sedation is not generally required.2
Tourniquet injuries are generally superficial, but may extend to the corporal bodies or
urethra. Often the initial diagnosis is mistaken for balanitis or paraphimosis due to significant
associated preputial edema. Prompt removal of the constricting band may require an exam under
anesthesia for adequate exposure. Identifying a hair tourniquet may be particularly difficult,
especially in the case of blond hairs. Loupe magnification during an exam under anesthesia
helps considerably in this situation. Local wound care may be used for isolated skin necrosis,
while more severe cases of corporal injury may require primary repair of cavernosal defects to
minimize the risk of fibrosis and preserve erectile function.2

Scrotal/Testicular Injury
Management
If physical examination and imaging, such as ultrasound, are indeterminate or suggest
significant testicular injury, early scrotal exploration is recommended. Rates of salvage in cases
of testicular rupture have been reported as high as 90% if performed within 72 hours. Early
exploration may also lead to decreased convalescent times and reduced risk of infection. In
cases of penetrating scrotal injury, a careful physical exam should be performed to determine the
depth of penetration and to ensure adequate cleansing and debridement.
In cases of suspected torsion, early exploration is also recommended. Testicular salvage
rates for torsion appear to increase with earlier exploration, with little benefit seen after 72
hours.92 In contrast, nonoperative management has been associated with orchiectomy rates of
approximately 45%.1 Animal studies suggest that early application of ice to the scrotum may aid
in the preservation of seminiferous tubules in testicular torsion.
Cases of isolated hematocele may be followed non-operatively in the absence of impaired
testicular flow. Isolated epididymitis may also be treated with supportive care including scrotal
elevation and nonsteroidal analgesics. In the absence of ischemic changes, testicular fracture
without disruption of the tunica albuginea may be observed. If nonoperative management is
selected, follow-up with both physical exam and ultrasonography should be used to monitor
resolution of injury.

Vaginal Injuries
Management
Operative management is seldom required for genital trauma in young girls.103
However, sexual abuse or assault may be identified in up to 25% of girls with genital injury.
Cystoscopy, vaginoscopy, and rectal exam should be performed to fully evaluate associated
injuries.1 Continuous flow of vaginoscopy aids in complete evaluation of the vagina, allowing
for removal of foreign bodies and coagulation of isolated mucosal bleeding. Gentle coaptation
of the introitus during endoscopic examination with irrigation allows for better distention and
visualization of the vaginal vault.
Perioperative use of antibiotics may help reduce the risk of secondary infection and wound
dehiscence. Postoperative care includes the avoidance of extremely lower extremity abduction,
stiz bathing, and the use of topical antibiotic ointments. For injuries that extend into the
introitus, the use of permanent monofilament sutures in an interrupted fashion is recommended
to reduce post-repair dehiscence risk.

Conclusions
Pediatric genitourinary trauma is uncommon and requires experienced subspecialists to optimize
care and minimize complications. Key principles of management include:

Indications for imaging pediatric trauma patients include penetrating injury, a history of
significant mechanism of injury, the presence of significant fractures or associated organ
injury, and the presence of hematuria >50RBC/hpf.

Abdominal and Pelvic CT scan with contrast is the most sensitive modality for diagnosis
and classification of pediatric genitourinary injury.

The majority of blunt renal injury can be managed non-operatively. The major decision
the urologist faces is when to surgically intervene in cases of grade IV and V injury.

A high index of suspicion is necessary to accurately and promptly diagnose ureteral

injury.

A delayed diagnosis of UPJ disruption or ureteral injury should be managed by

nephrostomy drainage and delayed repair.

The type of ureteral repair is dependent on the location and extent of injury
 Indications for imaging the lower urinary tract include penetrating injury, the presence of
gross hematuria with concomitant pelvic fracture, urinary retention or blood at the
urethral meatus.

The major determinant of bladder injury management is extraperitoneal vs intraperitoneal

injury.

Traumatic lacerations are more likely to involve the bladder neck and posterior urethra in
children.

The retrograde urethrogram is the most sensitive test for assessing urethral injury.

Acute management of urethral injury includes an assessment of bladder neck competency

and the establishment of continuous urinary drainage, preferably via a urethral catheter.

Posterior urethral disruption can be managed by immediate primary repair or late repair
with suprapubic drainage. The subsequent complications are related to the severity of
injury, not the management strategy.

Neonatal penile trauma is most often iatrogenic from circumcision injury

Ultrasonography is a valuable adjunctive tool to physical exam in evaluating scrotal

trauma

Examination under anesthesia should be used to fully assess the extent of genital trauma

Reference :

David J. Chalmers, Vijaya M. Vemulakonda. Genitourinary Trauma. Pediatric Urology Book.

May 10th, 2014. Available from :
http://www.pediatricurologybook.com/urinary_tract_trauma.html