UROLOGIC TRAUMA

Hao Pan
Department of Urology, the First
Affiliated Hospital, College of
Medicine, Zhejiang University

UROLOGIC TRAUMA:

Renal Injuries;

Ureteral Injuries;

Bladder Injuries;

Urethral Injuries;

External Genitalia Injuries.

 Of

all injuries to the genitourinary system,

urethral and renal Injuries are common.
Usually associated with other organs or
tissues injuries.
Hematuria is the best indicator of traumatic
injury to the urinary system.

Chapter 1:
Renal Trauma (etiology)
Blunt

renal injuries most often come from

motor vehicle accidents, falls from heights,
and assaults;
Penetrating renal injuries most often come
from gunshot and stab wounds;
Iatrogenic.
Renal tumor.

Classification:
American Association for the Surgery of Trauma Organ Injury Severity Scale for the Kidney

Symptoms and signs:

1. shock;
2. hematuria: microscopic or gross hematuria.
however, the degree of hematuria and the
severity of the renal injury do not correlate
consistently;
3. pain;
4. fever, due to secondary infection.

Diagnosis
Patient

history and physical examination;

Urinalysis, hemoglobin;
Ultrasound, immediate evaluation of injuries;
Computed tomography (CT) with contrast
enhanced (preferred imaging study );
Excretory urography, which has largely been
replaced by CT.
Arteriography.

 Grade

 Grade

II

 Grade

III

 Grade

IV

Grade IV

Management:
Nonoperative

Management,
Most renal injuries are Grade I, can be
managed nonoperatively.
1, hospital admission and bed rest for 2-4 weeks;

2, vital sign monitoring;

3, transfusion;
4, antibiotics;
5, close clinical follow-up.

Management:
Operative

Management ,

1, Absolute indications:

Persistent renal bleeding, expanding

perirenal hematoma, pulsatile perirenal
hematoma.
2, Relative indications:
Urinary extravasation, nonviable tissue,
delayed diagnosis of arterial injury, segmental
arterial injury, other organ injuries and
incomplete staging.

Management:
Operative

Management ,

Renal Exploration:
Transabdominal approach is recommended for
early exploration of the renal hilum and vasculature
to stop the bleeding.
reconstructive surgery or nephrectomy.

The surgical approach to the renal vessels and kidney: A, retroperitoneal

incision over the aorta medial to the inferior mesenteric vein; B, anatomic
relationships of the renal vessels; C, retroperitoneal incision lateral to the
colon, exposing the kidney.

Complications
1.Urinoma, perinephric infection, sometimes
perinephric abscess and renal loss, which usually
followed persistent urinary extravasation.
2. Delayed renal bleeding.
3. Hypertension, (1) renal vascular injury, leading to
stenosis or occlusion of the main renal artery or one of
its branches; (2) compression of the renal parenchyma
with extravasated blood or urine; (3) post-trauma
arteriovenous fistula. In these instances, the reninangiotensin axis is stimulated by partial renal ischemia,
resulting in hypertension.

Chapter 2:
Ureteral Injuries
Ureteral

injuries after external violence are

rare and can be missed because patients
often do not exhibit hematuria. Associated
visceral injury is common,
Diagnosis: delayed CT contrast images.

Chapter 2:
Iatrogenic Ureteral Injuries
Surgical

Injury, largely result from surgeries in

the pelvis (such as hysterectomy) and
retroperitoneum. Intimate knowledge of its
location is important.
Ureteroscopic Injury;
Radiation.

Classification:
American Association for the Surgery of Trauma Organ Injury
Severity Scale for the Ureter

Symptoms and signs:

1. hematuria;
2. Urinary extravasation;
3. Obstruction, hydronephrosis;
4. Urinary fistula.

Diagnosis
Patient history and physical examination;
Excretory urography, However, IVP findings are
often subtle and nonspecific.
Computed tomography (CT): extravasation of
contrast material.
Retrograde Ureterography (recommended).
simultaneous placement of a ureteral stent.

Methylene Blue injection intraoperatively.

Excretory urography
demonstrating extravasation in
the upper right ureter consequent
to stab wound. Note lack of
contrast (arrow) in the ureter
below the site of injury, indicating
complete ureteral transection.

Computed tomography showing right medial extravasation of

contrast material in a patient with a renal pelvis laceration.

Management:
1. Placement of a ureteral stent;
2. Ureteroureterostomy, or so-called end-toend repair, is used in injuries to the upper
two thirds of the ureter;
3. Transureteroureterostomy;
4. Ureteroneocystostomy.
5. Autotransplantation of the kidney;
6. Transposition of bowel to replace the ureter;
7. Nephrectomy.

Chapter 3:
Bladder Injuries
Bladder injury after blunt trauma is relatively
rare owing to the protected intrapelvic position of
the bladder. Sometime bladder rupture associated
with pelvic fracture.

1 extraperitoneal

2 intraperitoneal

Diagnosis
Retrograde

cystography is the traditional

imaging modality to diagnosis bladder
rupture;
CT scan;
Bladder filling test.

Plain film cystogram reveals extraperitoneal bladder rupture with

extravasation into scrotum. Surgical exploration revealed anterior
bladder neck and prostatic urethral laceration

CT cystogram demonstrates contrast material surrounding loops of

bowel consistent with intraperitoneal bladder rupture.

Management:
1

Urethral catheter drainage, which is

recommended in uncomplicated
extraperitoneal bladder ruptures;
2 Operative repair of the bladder.

A, Dense flame-shaped pattern of contrast agent extravasation in pelvis

due to extraperitoneal bladder rupture. B, Repeated cystogram in same
patient after 2 weeks of catheter drainage shows completely healed bladder

Chapter 4:
Urethral Injuries
Classification:
1. anterior urethra (below the urogenital
diaphragm);
2. posterior urethra (above the urogenital
diaphragm).

Anterior urethral injuries

Anterior urethral (below the urogenital
diaphragm) injuries are often associated with
straddle injuries, which are most often isolated .
The bulbar urethra is typically the site of injury.
Anterior urethral injuries are divided as
following: contusion, incomplete disruption, and
complete disruption.

In severe trauma, Buck's fascia may be disrupted,

resulting in blood and urinary extravasation into
the scrotum.

Clinical signs:

1 blood at the meatus

2 perineal hematoma,
3 gross hematuria,
4 urinary retention.

Diagnosis of anterior urethral

injuries :

1 Patient history and physical

examination;

2 Diagnostic urethral catheterization,

3 X-Ray: urethrography.

Management of anterior urethral

injuries:
1. Urethral catheter diversion alone;

2. Anastomotic urethroplasty;

3. In cases of severe anterior urethral

injury, suprapubic cystostomy may be
required, followed by delayed open surgical
repair.

Posterior urethral injuries

Posterior urethral (above the urogenital
diaphragm) injuries are often associated
with many other pelvic injuries;

Clinical signs:
1 presence of blood at the urethral
meatus;

2 inability to urinate,

3 palpably full bladder.

4 pain

5 shock
Urethral disruption is often first detected when
a urethral catheter cannot be placed or
misplaced into pelvic hematoma.

Diagnosis of posterior urethral injuries :

1 Patient history and physical
examination,
AAADRE;

2 X-Ray: urethrography.

Retrograde urethrogram in pelvic fracture patient shows

complete disruption of posterior urethra.

Management of Posterior urethral

injuries :
Suprapubic

Cystostomy, which is followed

by delayed combined antegrade and
retrograde endoscopic repair or open
surgical repair,
Primary Realignment, which is reasonable
in stable patients. When the urethral
catheter is removed after 4 to 6 weeks, it is
imperative to retain a suprapubic catheter
because most patients will, despite
realignment, develop posterior urethral
stenosis.

Complication:

1 Urethral stenosis;
2 Impotence;
3 Incontinence .

Chapter 5:
External Genitalia Injuries.
Penile

fracture usually occurs during sexual

intercourse or masturbation, which
sometimes associated with urethral injuries.
Testicular rupture .

Transverse laceration of right corpus cavernosum