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- 10. Renal Trauma: Diagnostic Algorithm Hemodynamically stable and clinical suspicion for renal injury: • Blunt trauma: gross hematuria or microscopic hematuria and a systolic blood pressure lower than 90 mm Hg at presentation. • Any penetrating trauma of abdomen, flank, and lower chest. Initial CT imaging if Precontrast imaging Depicts acute bleeding or intraparenchymal hematoma that may become isoattenuating relative to the normal renal parenchyma at postcontrast CT. It can also help identify calculus. Corticomedullary (35 sec) and nephrographic (75 sec) phases Help evaluate vascular and parenchymal injury, active bleeding, anatomic variants, and damage to other organs. Excretory phase (5–7 min) Depicts collecting system injury and helps differentiate between vascular injuries: pseudoaneurysm or arteriovenous fistula compared to active bleeding.
- 11. American Association for the Surgery of Trauma (AAST) Kidney Injury Scale (2018) Grade II Grade III Grade I Grade * Imaging Criteria (CT Findings) I Subcapsular hematoma without parenchymal laceration. II Perirenal hematoma confined to Gerota fascia. Renal parenchymal laceration at least 1.0 cm in depth without urinary extravasation. III Renal parenchymal laceration greater than 1.0 cm in depth without collecting system rupture or urinary extravasation. Any injury in the presence of a kidney vascular injury or active bleeding contained within Gerota fascia.
- 12. Grade IV Grad e Imaging Criteria (CT Findings) IV Parenchymal laceration extending into urinary collecting system with urinary extravasation. Renal pelvis laceration or complete ureteropelvic disruption. Segmental renal vein or artery injury. Active bleeding beyond Gerota fascia into the retroperitoneum or peritoneum. Segmental or complete kidney infarction due to vessel thrombosis without active bleeding. AAST Kidney Injury Scale (2018)
- 13. Gra de Imaging Criteria (CT Findings) V Main renal artery or vein laceration or avulsion of hilum. Devascularized kidney with active bleeding. Shattered kidney with loss of identifiable parenchymal renal anatomy. Grade V AAST Kidney Injury Scale (2018)
- 14. Renal Trauma: Sample Cases In a 45-year-old man after blunt trauma shows a contained subcapsular nonexpanding hematoma (circle). In a 38-year-old man after blunt trauma demonstrates a hematoma confined to the retroperitoneum with laceration less than 1.0 cm (circle). A 56-year-old man after blunt trauma reveals a laceration (more than 1.0 cm parenchymal depth) without collecting system rupture (circle). Grade I Grade II Grade III 1 2 3
- 15. Grade IV Laceration Parenchymal laceration extending through the renal cortex, medulla, and collecting system . A posterior perinephric hematoma is seen . Laceration Blunt trauma shows shattered kidney (separated areas of vascularized and devascularized parenchyma) and expansive hematoma . Vascular Blunt trauma demonstrates an area of infarction in the inferior polar region of the left kidney supplied by an inferior polar accessory artery with filling defects due to traumatic occlusion. Grade V Vascular Shows a filling defect and hematoma on left renal artery (arrow) due to traumatic occlusive thrombus, associated with a left anterior perinephric hematoma (oval). Parenchymal enhancement is absent in the left kidney, which is completely devascularized . Renal Trauma: Sample Cases 4 A 4 B 5 A 5 B *
- 22. Ureteral Trauma: Diagnostic Algorithm Hemodynamically stable and clinical suspicion for ureter injury: • Patients with complex multisystem abdominopelvic trauma such as those with bowel, bladder, or vascular injuries. • Complex pelvic or vertebral fractures. • After rapid deceleration injuries. • When the trajectory of the penetrating injury is near the ureter, especially in cases of high- velocity gunshot wounds. Initial CT imaging if Multiphase CT • Imaging method of choice for ureter injury evaluation and abdominal evaluation in the context of polytrauma. • The main finding is extravasation of contrast media from ureters during excretory phase.
- 23. Grade* Injury type Description I Hematoma Contusion or hematoma without devascularization. II Laceration Less than 50% transection. III Laceration At least 50% transection. IV Laceration Complete transection with less than 2.0 cm of devascularization. V Laceration Avulsion with greater than 2.0 cm of devascularization. * Advance one grade for multiple lesions up to grade III. Source.—References 2 and 3. Grade II Grade V Grade III Grade I Grade IV AAST Ureter Injury Scale
- 30. Bladder Injury: Diagnostic Algorithm Hemodynamically stable and clinical suspicion for bladder injury: • Gross hematuria. • Pelvic fracture. Initial Imaging if CT Cystography • Accuracy rate: 95%. • Active distention of bladder: 300–350 mL of diluted contrast media instilled into the bladder. • CT imaging of the pelvis. • Passive filling of bladder with excretory phase of CT is not reliable • Multiplanar reformation is helpful in detecting site of rupture. Conventional Cystography • Accuracy rate: 85%–100%. • Fluoroscopic guidance. • Sequence of films: 1. Initial radiography of the pelvis. 2. Maximally filled bladder. 3. Postdrainage film (depict extraluminal contrast material leak).
- 31. Grade * Injury type Description I Hematoma Contusion or intramural hematoma. Laceration Partial thickness. II Laceration Extraperitoneal bladder wall laceration less than 2.0 cm. III Laceration Extraperitoneal (greater than 2.0 cm) or intraperitoneal (less than 2.0 cm) bladder wall laceration. IV Laceration Intraperitoneal bladder wall laceration greater than 2.0 cm. V Laceration Intraperitoneal or extraperitoneal bladder wall laceration extending into the bladder neck or ureteral orifice (trigone). Grade I Grade II Grade III Grade IV Grade V AAST Bladder Injury Scale
- 32. 1 Contusion Normal. 2 Intraperitoneal (IP) Rupture Contrast material surrounding IP structures and accumulated in paracolic gutters or pouch of Douglas. 3 Interstitial Bladder Rupture Contrast material dissects into the bladder wall. There is no contrast material extravasation. 4 Extraperitoneal (EP) Rupture 4A EP: Simple Contrast material is limited to the perivesical space. 4B EP: Complex Contrast material spreads to all EP pelvic floor and may dissect the retroperitoneum, causing confusion with IP rupture. 5 IP and EP Rupture Combination of features from grades 2 and 4.
- 39. Grade Injury type Description I Contusion Blood at urethral meatus and normal urethrography. II Stretch injury Elongation of urethra without extravasation at urethrography. III Partial disruption Extravasation of urethrography contrast material at injury site with visualization in the bladder. IV Complete disruption Extravasation of urethrography contrast material at injury site without visualization in the bladder. Less than 2.0 cm of urethra separation. V Complete disruption Complete transection with at least 2.0 cm of urethra separation or extension into the prostate or vagina. Grade I Grade II Grade III Grade IV Grade V * * AAST Urethra Injury Scale
- 40. 1 Stretching injury to the prostatic urethra but no disruption. Rupture of the puboprostatic ligaments. 2 Disruption of the prostatic urethra. Contrast leak above the urogenital (UG) diaphragm. 3 Disruption of the membranous urethra. Contrast leak into and below the UG diaphragm. 4 Disruption involving the bladder neck. Repaired surgically (internal sphincter is fundamental for continence). 4a Bladder base rupture not involving bladder neck. Can be managed conservatively. 5 Disruption of the anterior urethra. Repaired surgically. Goldman Type Injury Description Notes
- 41. ( AAST Grades IV and V B A C D Goldman Type 2 Urethral Trauma: Sample
- 42. C B AAST Grade V A Goldman type 3 Urethral Trauma
- 46. Hemodynamically stable and clinical suspicion for penile injury: • Penile ecchymosis and swelling. • History of cracking or snapping sound during intercourse or manipulation and immediate detumescence. • Penile pain and angulation. • Penetrating trauma should be examined with direct surgical exploration. Initial Imaging if Direct Surgical Exploration • If penetrating injury. US • Widely accessible. • Linear transducers • Characterize the nature and extension of the injury. • Depict the exact location of the tear as an interruption of a thin echogenic line (tunica albuginea). • Hematoma may be seen deep to the skin or Buck fascia. MRI • Good spatial definition. • Depicts the location of the tear as a discontinuity of the low signal intensity of the tunica albuginea at T1- and T2-weighted imaging. Penile Trauma: Diagnostic Algorithm
- 47. Grade* Description I Cutaneous laceration or contusion. II Buck fascia (cavernosum) laceration without tissue loss. III Cutaneous avulsion, laceration through glans or meatus, or cavernosal or urethral defect of less than 2.0 cm. IV Partial penectomy. V Cavernosal or urethral defect 2 cm or greater or total penectomy. * Advance one grade for multiple lesions up to grade III. Source.—Reference 2. Grade I Grade II Grade III Grade IV Grade V AAST Penis Injury Scale
- 48. Grade Radiographic Appearance 0 Absence of defect in tunica albuginea. This type may be associated with soft-tissue hematoma. 1 Minimal defect of tunica albuginea and adjacent corpus cavernosum that appears as a hypoechoic or anechoic defect in these structures. 2 Minimal defect of tunica albuginea and adjacent corpus cavernosum with perialbugineal and cavernosal hematoma formation. 3 Moderate fascial plane disruption with the involvement of tunica albuginea, Buck fascia, and the corpus spongiosum, usually seen as hematoma contained by Colles fascia. 4 Major disruption affecting spongiosum and urethra. Urethra may become visible at US with blood inside.
- 49. AAST Grade II
- 50. AAST Grade III AAST Grade IV U US Grade V US Grade II
- 53. Grade* Description I Contusion or hematoma. II Subclinical laceration of tunica albuginea. III Laceration of tunica albuginea with less than 50% parenchymal loss. IV Major laceration of tunica albuginea with at least 50% parenchymal loss. V Total testicular destruction or avulsion. Grade I Grade II Grade III Grade IV Grade V AAST Testis Injury Scale
- 54. Injury US Findings Testicular rupture Tunica albuginea rupture, contour irregularity, heterogeneous echotexture of testis. Fracture Linear, hypoechoic avascular area within testis with or without tunica albuginea rupture. Hematoma Variable appearance depending on hematoma age: echogenic to anechoic or complex. Dislocation Testis absent from scrotum. Torsion Blood flow absent from testis. Pseudoaneurys m Yin-yang sign and to-and-fro flow pattern at color and spectral Doppler US imaging. Hematocele Variable appearance: echogenic (acute) to complex anechoic (chronic). Penetrating trauma Missile track, air inside or outside testicular parenchyma, presence of foreign bodies.
- 56. (2A, 2B) US images obtained in a 38-year-old man after blunt trauma demonstrate a disruption of the tunica albuginea (red arrows) of the left testicle with less than 50% parenchyma loss (yellow *) with heterogeneous echotexture of the testicular parenchyma associated with an extratesticular hematocele (red *) and hydrocele (blue *). (1A, 1B) Doppler US images obtained in a 28- year-old man after blunt testicular trauma show an expansive hematocele (red dashed line) compressing the right testicle (*) associated with a small tunica albuginea lesion (red arrow) without parenchymal loss. 2A * 2B * 1A 1B * * * * * * Scrotal and Testicular Trauma Scrotal and Testicular Trauma
- 57. A B *
Editor's Notes
- The American Urological Association and the European Association of Urology have recently updated their guidelines for CT in renal trauma.
- Grade based on highest grade assessment made at imaging, at operation, or at pathologic analysis. More than one grade of kidney injury may be present and should be classified by using the higher grade of injury. Advance one grade for multiple injuries up to grade III. Source.—Reference 2.
- Persistent collecting system leaks may be treated with nephrostomy or a double-J ureteral catheter insertion (Fig. 36.11). Surgical repair may be required if non-surgical interventions do not resolve the leak artial UPJ disruption can be managed with transurethral double-J catheter stenting, whereas large or complete disruptions require operative repair
- Management: Avulsion of the renal vasculature requires urgent surgical intervention, as the patient is typically haemodynamically unstable. A shattered kidney usually necessitates nephrectomy. However, in selected cases, non-operative management, supplemented by renal angiography and percutaneous drainage, if needed, can be attempted, even in cases of major renal parenchymal disruption
- In general the trend is towards nonoperative management for all but most severe injuries.8 Grade 1-3 injuries, which constitute >90 percent of all renal injuries, are almost always managed conservatively Most of grade 4 injuries can also be managed conservatively.
- Contusions and small subcapsular haematomas are managed conservatively and do not require routine follow-up. The presence of a large subcapsular haematoma resulting in renal compression or tamponade can initially be managed expectantly; however, occasionally, surgical evacuation is required
- (A) Axial unenhanced multidetector computed tomography image shows a large left perinephric haematoma (asterisk). (B) Axial portal venous phase imaging demonstrates a high-density focus representing a pseudoaneurysm (arrow), which remains isodense to the aorta on delayed images (C).
- DSA image (A) of selective left renal artery injection in a patient injured with multiple pellets shows pseudoaneurysm formation with active bleed (arrow) in upper pole of left kidney. The involved upper polar segmental branch was selectively embolized with coil (arrow in B) resulting in thrombosis of pseudoaneurysm
- SUMMARY BOX: Renal Injury • Blunt trauma most common. • Haematuria not always present. • More common in paediatric population and those with congenital anomalies. • Multiphase MDCT, including delayed-phase imaging, is essential for accurate diagnosis. • AAST grading system—management depends on grade of injury and haemodynamic status of patient: • Grades I to III most common. Generally conservative management • Grade IV increasingly managed by watchful waiting and interventional radiology • Grade V are uncommon but frequently require surgery.
- . Patients undergoing gynaecological surgery are at the highest risk, Penetrating injury to the ureter involves the upper portion of the ureter in 70% of cases.
- Axial delayed-phase multidetector computed tomography (MDCT) image demonstrates fluid within the pelvis (asterisk) with extravasation from a laceration in the distal right ureter (arrow). (B) Coronal maximum intensity projection (MIP) MDCT image shows extravasation from the right distal ureter (arrow). Management: Iatrogenic ureteric injury should be repaired at the time of surgery if identified.
- Management: Iatrogenic ureteric injury should be repaired at the time of surgery if identified. Ureteric lacerations can be managed by double-J catheter insertion, while complete transection typically requires a diverting nephrostomy prior to definitive treatment
- Ureteroneocystostomy (UNC) refers to reimplantation of the ureter into the bladder.
- IBR occurs more frequently in small children in motor vehicle accidents than in adults, as the seat belt fits over the anterior lower abdomen rather than the superior iliac spines and the bladder is positioned in the lower abdomen rather than deep in the pelvis.
- CT cystography should be done in all patients with known pelvic fractures or in patients with gross hematuria or severe pelvic trauma with no known pelvic fractures.
- Type 1, 3 and 4 injuries are managed conservatively with placement of a foleys catheter. However intraperitoneal rupture of bladder requires surgical repair. Hence type 2 and 5 injuries are managed surgically.
- Intrperitoneal rupture
- EXTRAPERITONEAL Molar tooth appearance Type 1, 3 and 4 injuries are managed conservatively with placement of a foleys catheter. However intraperitoneal rupture of bladder requires surgical repair. Hence type 2 and 5 injuries are managed surgically.
- Computed tomography cystogram of trauma patient with extraperitoneal bladder rupture shows extensive streaky extravasation into the fascial planes of the pelvis. intraperitoneal bladder injury demonstrates high-density fluid surrounding bowel loops. (B) Coronal reformatted multidetector computed tomography image shows the precise site of bladder injury at the bladder dome.
- • BLADDER SUMMARY Blunt trauma most common. • Haematuria typically present. • Most patients will have concurrent pelvic fractures. • May be extraperitoneal rupture (most common), intraperitoneal rupture or mixed. • Computed tomography cystography required for accurate diagnosis. • Most EBRs managed conservatively (suprapubic or transurethral catheter) —90% healed in 10 days. IBRs usually require surgery
- Imaging alone is insufficient to identify the grade of the lesion according to the AAST Ureter Injury Scale. The Goldman classification is the most used system to classify urethral trauma in medical practice. Steep oblique films are obtained, at the end of injection of 25-30 ml of 50 percent contrast.
- A) Oblique retrograde urethrogram obtained in a 49-year-old man after blunt pelvic trauma shows a posterior urethra lesion with contrast media extravasation (red arrow). (B-D) Axial contrast-enhanced CT urethrograms demonstrate the catheter in the urethra (blue circle) and extraperitoneal pelvic extravasation of the contrast media (yellow arrows). Fractures of the left superior and inferior pubic rami as well as right sided sacral ala with diastasis of the pubic symphysis are seen (green arrows).
- B. show a bulbomembranous urethral injury with progressive extravasation of contrast media above and below the urogenital diaphragm (blue circle) without opacification of the urinary bladder. (C) Oblique combined urethrogram obtained 1 day after undergoing a suprapubic cystostomy (red arrow) demonstrates the integrity of bladder walls. Partial filling of the cephalad portion of the prostatic urethra is revealed on the cystogram (green arrow). Retrograde urethrogram shows contrast filling up to the bulbomembranous junction with contrast extravasation (yellow arrows). (grade V). Fractures of the left superior and inferior pubic rami are seen (blue arrows).
- URETHRAL TRAUMA Most common in men following high-velocity trauma. • Found in 10% of significant pelvic fractures. • Missed in approximately one-fifth of patients at initial assessment—check catheter position on CT. • Urethrography used for diagnosis. • MRI provides accurate grading and assessment of complications.
- Since the most frequent type of penile trauma is penile fracture (blunt), an ultrasonographic classification system was proposed.
- Sagittal T2-weighted (A) and axial T1-weighted postcontrast (B) fat-suppressed MR images in a 33-year-old man obtained 2 weeks after penile fracture during intercourse show a hypointense scar sequelae (yellow arrows) in the tunica albuginea at the ventral region of the right cavernosum (no tissue loss) associated with mild enhancement of the surrounding soft tissue (red arrows).
- Short-axis US image of the base of the penis obtained a hypoechoic breach in the tunica albuginea covering the right cavernosum (red arrow), with an associated hematoma between the right corpus cavernosum and the corpus spongiosum (blue oval). V = ventral, D = dorsal, C = cavernosum, U = urethra. US image during intercourse shows a urethral catheter (yellow arrows) and a hyperechogenic bulbar urethra lesion (1.4 cm) (red arrows) associated with the penile fracture. A hematoma in the corpus spongiosum is seen (white arrow).
- demonstrate a mild soft-tissue or subcutaneous hematoma in the scrotum (red dashed line). a large hematocele (red dashed line) surrounding the left testicle (*). (2B) Color Doppler US image reveals the presence of vascularization in the testicle.
- Doppler US image obtained in a 20-year-old man after blunt scrotal trauma demonstrates a diffuse heterogeneity of testicular echogenicity with intratesticular hematomas (red arrows) and a large amount of hematocele (*) surrounding the inferior portion. Note the blurring of testicular contour in the inferior pole of the testicle (yellow dashed line). (B) Color Doppler US image shows the presence of vascularization in the left testicle.