1. The document discusses the management of various types of urinary tract injuries including renal, ureteric, bladder and urethral injuries. 2. It provides clinical scenarios for each type and discusses their relevant anatomy, epidemiology, signs and symptoms, investigations and treatment approaches. 3. Management depends on the grade of injury and may involve conservative approaches, surgical exploration or repair, with the goal of preserving renal function and maintaining hemodynamic stability in trauma patients.

1. Management of
Urinary Tract Injury
Moderator
• Prof. H. S. Pahwa (MS,MCh)
• Dr. Ajay Kr Pal (MS)
Presented by-
• Dr. Debmoy Ghatak (JR3)

2. Overview
Clinical Scenarios-
Relevant Anatomy of the urinary tract-
Epidemiology-
Organ Specific Injury-
• Renal
• Ureteric
• Urinary Bladder
• Urethral
MIST Protocol-
• Mechanism of Injury-
• Injuries associated-
• Sign and symptoms-(& Investigations)
• Treatment (Management)

3. Clinical Scenarios-Renal Injury
• Scenario- 1 –
• A 47-year-old man who sustained a high-impact injury in a road traffic accident
and had ongoing left loin pain and gross hematuria on admission.
• He was hemodynamically stable.
• He had # left 12 and 11th rib with a substantial bruise locally over left flank with
abrasion.
• On exam he had a ballotable tender lump left flank.
Case Rep Urol. 2012; 2012: 207872

4. Clinical Scenarios-Ureteric Injury
• Scenario- 2-
• A 34-year-old woman was transferred to ER from another
hospital after removal of a knife from the RUQ of her abdomen.
She complained of tenderness in the entire abdomen. Her initial
vital signs were stable, a 5-cm laceration in her abdominal RUQ.
Laboratory examination results were wnl except for TLC of
20,890/mm3.
• She had persistant hematuria and right hip irritation with
difficulty straigtening right hip
• [Trauma Case Reports,Volume 21, June 2019, 100197]

5. Clinical Scenarios-Urinary Bladder
• Scenario- 3-
• A 29-year-old woman presented to the ER following a RTA. Gradually she
developed severe lower abdominal and flank pain, gross hematuria, and
appeared lethargic and confused, but had not experienced head trauma
during the collision.
• She was afebrile, tachycardic, with normal BP. Her abdomen was distended
and guarded with rebound tenderness.
• There was frank blood at the urethral orifice and introduction of a bladder
catheter yielded no urine.
• Plain radiographs of the pelvis revealed Type B left pelvic #. Laboratory data
were significant for a hemoglobin of 12.0 mg/dL, leukocytosis of 15.1 x
103 WBC/μL, and elevated serum creatinine of 1.57 mg/dL.
• Int J Surg Case Rep. 2019; 55: 160–163

6. Clinical Scenarios- Urethral Injury
• Scenario- 4-
• A 46 yr old man following an RTA presented with acute retention of urine with
blood at urethral meatus with hypogastric lump with pelvic pain and inability to
move right lower limb.
• Upon further investigation he was found to have a Type A open book pelvic
fracture with right intertrochanteric fracture with BP 92/66 mmHg, HR-108/min,
HB-8.9 gm/dl with TLC-13400/dl.
• The RGU shows abrupt cut off of dye in penile urethra.

7. Relevant Anatomy
Kidneys
• The kidneys are essentially
retroperitoneal structures lying on
each side of the vertebral column.
• Their hila at the level of L1, the
transpyloric plane.
• Though protected partially in the
posterior lower thoracic cage they
are prone to injury .

8. Double Injury- Concomitant Liver injury with
right kidney trauma
Triple Injury- Concomitant Splenic and colonic
injury with left kidney injury

10. Ureter-
• Anatomically, the ureter is 22 to 30 cm in length
and divided into three portions:
• There are three narrowings in the ureter:
at the pelviureteric junction, at the brim of the
pelvis and on entering the bladder.
• A stone or blood clot may impact at these sites,
causing ureteric obstruction.

13. Urinary Bladder
• Though it’s an intrapelvic organ
it becomes intra-abdominal
while full.
• It’s highly vascular – upon
repair it heals satisfactorily !

15. Epidemiology-
• G.U. injury occurs in 2–5% of all trauma patients.
• At least 10% of patients with abdominal trauma.
• The percentage of blunt and penetrating trauma varies dramatically .
• Overall, approximately 90% of significant renal injuries are due to blunt trauma
• In some urban trauma centres, penetrating injuries predominate.
• For penetrating trauma, nearly all renal gunshot wounds are associated with
injuries to other intra-abdominal organs; for renal stab wounds, approximately
60% of cases occur in combination with another intra-abdominal injury.
ATLS 10th ed

16. Renal Trauma
• The kidneys are the most commonly injured
GU organs in blunt trauma.
• Children are more prone
• Tall thin individuals
• Predisposed Kidney.
• Significant acceleration/deceleration can
cause rare but lethal renovascular injuries
specially pediatric age group.
• Ipsilateral rib fracture can increase
the incidence of significant renal trauma
threefold.

17. MECHANISM OF
INJURY
• Blunt trauma-[usually
associated with solid visceral
injury]
• RTA(Deceleration ),
• Fall of heavy object
• Fall from Ht
• Sports Injury- A kidney Punch!
• Penetrating abdominal
injury- [usually associated
with hollow viscous injury]
• Stab injury
• Gunshot Injury
• Blast injury

18. Grades of Renal Injury

20. Signs and Symptoms-
• History of significant thoracoabdominal trauma
• Local-
• Urinary Symptoms-
• Hematuria- It does not consistently correlates with
DEGREE OF RENAL Injury !
• It may be Immediate- Delayed (Tardive Hematuria –
even after two weeks !)
• It may be Gross or Microscopic (Def- >= 5 RBCs /
HPF in sedimented sample of FRESHLY VOIDED
URINE)
• Clot Colic
• Acute Retention d/t clots
• Meteorism
• Systemic Features-
• Anxiety
• Hypovolumic Shock
• Predictor of significant renal injury- the
presence of penetrating trauma/ blunt
trauma with gross hematuria / blunt
trauma with microhematuria and shock.

21. Clinical features-
• Signs-
• LOCAL ABDOMINAL SIGNS-
• Skin- Bruise at flanks / Entry-
Exit wound of GSW / Stab
wound
• Tender Ballotable flank lump
• Flank Tenderness
• Hypogastric Bladder lump
with acute retention of urine
• Even abdominal distension
due to ? Bowel injury ? Ileus
• SYSTEMIC-
• Tacycardia
• Hypotension
• Postural Hypotension

22. Modes of Investigation
Commonly
Used
USG FAST
USG KUB
IVP- Single
Shot.
CECT W/A.
Rarely
Used
CT Angiography
Renal Vascular
doppler

23. USG FAST
Focused Assessment with Sonography for Trauma
• FAST is an accepted, rapid, and reliable study
for identifying intraperitoneal fluid.
• FAST includes examination of four regions:
• The pericardial sac,
• Hepatorenal fossa,
• Splenorenal fossa,
• Hypogastrium/pelvis or pouch of Douglas .
• BUT- FAST falls short of assessing
retroperitoneal structures properly.

24. USG showing trauma to right
kidney with significant
subcapsular hematoma
compressing renal parenchyma
–without obvious parenchymal
lacerations-
Grade I AAST Renal Injury
USG KUB

25. Single Shot IVP-
Intra Venous
Pyelogram
• IVP was considered an accurate tool for clinical
staging purposes in 60–85% of patients until
the advent of CT.
• Procedure-
• A high-dose, rapid injection of renal contrast
(“screening IVP”) is performed using 2 ml of
iodine/kg body weight.
• Only a single film is taken 10 minutes after the
IV push.

26. IVP- Intra
Venous
Pyelogram
• Unilateral renal nonvisualization occurs with
an
• Thrombosis, or
• Avulsion of the renal artery, and
• Massive parenchymal
disruption.
• Renal agenesis
• Non-visualization ?- further radiologic
evaluation.
• Single shot IVP is used Intraoperatively for
assessing status of renal function in
haemodynamically unstable patients who
failed to underwent CT W/A.

27. • CECT scan has become the GOLD
STANDARD for precise staging of
renal injuries and has largely
replaced IVP in most clinical settings.
Contrast Enhanced CT WHOLE
ABDOMEN With IV CONTRAST

28. • Markers of severe renal injury in CT-
1. Medial Hematoma
2. Medial Urinary extravasation
3. Global lack of contrast enhancement
4. The combination of two or more of the following-
• large hematoma grater than 3.5 cm or
• medial renal laceration or
• vascular contrast extravasation.
Campbell-Walsh Urology
CECT WHOLE ABDOMEN WITH IV
CONTRAST

29. Grade I Hematoma
(white arrow indicates right renal
subcapsular hematoma)
Grade II Hematoma
AAST Renal Trauma

30. Grade II Laceration
(white arrow indicates left renal parenchymal
<1 cm laceration)
Grade III Laceration without urinary
extravasation.
(black arrows indicate left renal
parenchymal >1 cm laceration)
AAST Renal Trauma

31. Grade IV vascular with vena cava thrombus
(white arrow indicates IVC thrombus and
black arrow indicates right renal vascular
compromise)
Grade IV laceration with extravasation
(white arrow indicates left renal
parenchymal/collecting system laceration)
AAST Renal Trauma

32. Grade V shattered Left kidneyGrade V Right Vascular Injury
AAST Renal Trauma

33. Management
• As with all trauma cases, a systematic approach following the
principles of Advanced Trauma Life Support (ATLS) should be
applied—ensuring that airway, breathing, and circulatory dysfunction
are assessed and treated appropriately in the first instance -
• Primary Survey with Simultaneous Resuscitation
• A-Airway and C-spine stabilization-
• B-Breathing and Ventilation
• C-Circulation and haemorrhage control
• D-Disability (Neurologic Evaluation)- GCS
• E- Exposure in controlled environment.

34. Management of Renal Trauma
• Managed conservatively. [Campbell urology]
Grade I and II
Renal Injuries
• Current evidence favors the nonoperative
approach.
Grade III Renal
Injuries
• Conservative management of in the majority of
cases preserves renal function as measured by
DMSA scintigraphy[J Urol. 2012 Apr; 187(4):1306-9.]
Grade IV Renal
Injuries

35. Keep in Surgical HDU &
Monitoring of vital signs.
Serial abdominal exam & Serial
CBC and S/E
Rest and analgesia Antibiotic
cover where appropriate
Typed and cross-matched blood
should be available beforehand
for the first 24–48 hours.
Conservative
management
The goal is to maintain the Hb in such a range that a sudden drop for a renewed bleeding would not be catastrophic

36. Management of Renal Trauma
INDICATIONS FOR RENAL EXPLORATION [by McAninch and Carroll ]
[Urol Clin North Am. 16(2):203–212 ]
• Hemodynamic instability.
• An ongoing hemorrhage requiring significant transfusion.
• Pulsatile or expanding hematoma .
• Avulsion of the pedicle.[Grade V Renal -AAST]
Relative indications
• High-grade injuries
• Large perirenal hematoma
• Presence of urinary extravasation on contrast studies
• Significant devitalized fragments of parenchyma
Penetrating renal injuries in cases where laparotomy will occur regardless, operative
management is widely recommended.

37. Operative management for Renal Trauma
• Wedge resectionSuperficial Parenchymal Graze
• Partial NephrectomyPolar injury
• Partial NephrectomyReconstructable kidney in an
unstable patient
• Total NephrectomyUnreconstructable kidney
• Total NephrectomyGrade V AAST parenchymal injury

38. Management of Renal Trauma
Renal Conservation
Wedge resection

39. Management of Renal Trauma
Partial Nephrectomy
for a polar injury

40. Complications of Renal trauma
• Urinoma- do ureteral stenting or external
diversion – percutaneous nephrostomy.
Early
complications-
• Delayed renal bleeding <21 days- give rest and
hydration and if persistent bleeding occurs do
CT Angiography and selective embolization.
• Peri nephric abscess-percutaneous drainage
• Renovascular Hypertension- give RAAS
inhibitors.
• Post traumatic A-V fistula.
Late
complications-

42. Ureteric Trauma
• Ureteral trauma is uncommon, accounting for
less than 1% of all urologic trauma.
• Can result in significant morbidity and mortality.
• These patients often have significant concomitant
injuries and a devastating degree of mortality that
approaches one third.
• A significant percentage (10% to 28%) of patients
with ureteral injuries also has associated renal
injuries.
• The overall incidence varies between 0.5% and
10% as Iatrogenic ureteral injuries and the toll is
as following hysterectomy (54%), colorectal
surgery (14%), pelvic procedures such as ovarian
tumor removal (8%).
• Campbell-walsh Urology.

43. Mechanism of injury-
• Blunt trauma-[usually associated with solid
visceral injury]
• RTA
• Fall of heavy object
• Deceleration injury
• Sports Injury
• Penetrating abdominal injury- [usually associated with hollow viscous
injury]
• Stab injury
• Gunshot Injury
• Apart from these major INTRAABDOMINAL AND PELVIC SURGERIES are
one of the causes of iatrogenic ureteric injuries.

44. Ureteric Trauma- Sign and Symptoms
• Ureteric injury is a great masquerader.
• Apart from h/o of significant trauma- blunt or
penetrating,
• Hematuria is an important sign of ureteral injury, it
may be absent 15–45% cases.
• A high index for suspicion of ureteral injury is
critical.
• For concomitant psoas injury localizing hip signs
may be present (Psoas irritation)
• Ureter is one of the most common sites of missed
injury during laparotomy, a published report
showed even as high as 11 % injuries can be
missed.
Mattox 8th Ed.

45. Ureteric Trauma-Investigations
Non Invasive
Imaging-
• IV Contrast Enhanced
Abdominal /Pelvic CT
with 10 [5-20 mins]
minute delayed images.
[AUA Urologic trauma guideline-Statement
9a]
• IVP With Delayed
Excretion Phase- Intra
OP –Single Shot IVP
Invasive Imaging-
• Upon failure of
noninvasive imaging -
Cystoscopy with
retrograde pyelography
and possible ureteral
stent placement.

46. AAST Grading of Ureteric Injury-

47. Ureteric Trauma- Management
• Nonoperative management of ureteral trauma
has limited applications.
• Grade 1 AAST- Ureteral contusions recognized
intraoperatively, due to either penetrating or
blunt trauma, may be managed nonoperatively
and observed.
• Grade 2 and higher injuries need operative
management.
• Ureteral repair should be performed at the time
of initial laparotomy, when possible [Guideline
Statement 10a. AUA]
In nonoperative management-
• Retrograde ureteropyelography with
attempted retrograde ureteral stent
placement is often performed.
• Alternatively, percutaneous renal
drainage may be the treatment of
choice.
Guideline Statement 11a and 11b-AUA

48. Ureteric Trauma- Management
• For proximal and mid-ureteral
injuries, limited debridement of
damaged tissue and a tension-free,
spatulated end-to-end anastomosis
over an intraluminal stent is the
procedure of choice.
• In the distal ureter (below the
internal iliac artery), ureteral
reimplantation into the bladder is
preferred.

49. Ureteric Trauma- Management
• Ureteroureterostomy
• UreteropyelostomyUpper 3rd
• Ureteroureterostomy
• Transureteroureterostomy
• Anterior wall bladder Boari Flap
Middle 3rd
• Psoas hitch
• UreteroneocystostomyLower 3rd
Grade II-IV
AAST
Injuries

50. Ureteric Trauma
Management
Ureteroureterostomy
• Stented
• Spatulated
• End to end
• Water tight
• Tension free

51. Ureteric Trauma-
Management
Trans-Ureteric-Ureterostomy

52. Ureteric Trauma-
Management
Anterior Bladder Flap-Boari Flap

53. Ureteric Trauma- Management- Psoas hitch

54. Ureteric Trauma-
Management
Ureteroneocystostomy-
• Modified Lich Gregoir Technique.
• For intra op diagnosis of very distal
injuries, a vertical cystotomy with
observation of efflux from the ureteral
orifices and intraoperative retrograde
pyelography.
• Alternatively, intraoperative flexible
cystoscopy with retrograde pyelography
may be performed.

55. Bladder Trauma
• Injury to urinary bladder is rarely an
isolated injury and most commonly
associated with many non-urologic
injuries.
• Most common association is with
pelvic fracture 83%- 95%.
• Nearly half of the bladder rupture are
iatrogenic.
Campbell-Walsch Urology

56. Mechanism of injury-
• Blunt trauma
• Penetrating abdominal injury-
• Most commonly associated with pelvic fractures.
• Even bladder rupture may occur with out pelvic
fracture when sudden force applied to an already
distended bladder leading to rapid increase in
intravesical pressure.
• Half of the bladder ruptures are iatrogenic- (Dobrowski et
al 2005)
• Obstretic and gynaecologic complications are the
most common causes of bladder injury during open
surgery. Campbell-Walsh Urology

57. Bladder Injury- Types
Bladder Injury
Intra-peritoneal
Bladder Rupture
Extra-peritoneal
Bladder Rupture
Combined
Variety

58. Bladder Trauma- Sign and symptoms
Significant history of trauma
Lower abdominal pain
Inability to void
Suprapubic or perineal ecchymosis.
Cardinal sign - Gross hematuria, [+ in >95% cases, 5%
has microscopic hematuria .]
An associated pelvic fracture.
An association of bladder rupture with
disruption of the posterior urethra, along with
the occurrence of a pelvic fracture, may occur in
10–20% of patients. Mattox Trauma Surgery 8th Ed
Intra peritoneal rupture may present with
abdominal distension, guarding, rigidity, ileus.

59. Bladder Trauma
• Cystogram with post-void film is the
standard method for diagnosis-
• The standard volume of filling is 300–
400 mL of iodinated contrast (30%
iodine commonly utilized) which is
infused through the indwelling Foley
catheter by gravity.
• Alternatively, the bladder can be filled
by gravity to a point at which the
patient describes a sense of bladder
fullness.

60. Cystogram
• A dense, flame-shaped collection of
contrast material in the pelvis is
characteristic of extraperitoneal
extravasation.
• Intraperitoneal extravasation is
identified when contrast material
outlines loops of bowel and/or the
lower lateral portion of the
peritoneal cavity.

61. Bladder Trauma
• CT Cystograms are the investigation of
choice.
• It is advantageous for the-
• Speed to obtain the images,
• Accuracy of extravasation detection,
• The lack of need for voiding images.
• Proper delineation of other organ injuries.

62. AAST Grading of Urinary Bladder Injury

63. Bladder Trauma- management
Intraperitoneal bladder
rupture
Grade III,IV,V
• Surgical repair
• (Standard; Evidence
Strength: Grade B)
Uncomplicated
extraperitoneal bladder
injuries
Grade I & II
• Catheter drainage and
conservative treatment.
• (Recommendation;
Evidence Strength: Grade
C)
Complicated
extraperitoneal bladder
injury –i.e. Non-healing
extraperitoneal rupture d/t
jutting fragment of pelvic #.
• Surgical repair
• (Recommendation;
Evidence Strength: Grade
C).
AUA Guidelines suggest-

64. Bladder Trauma- Management
• In selected cases, flexible cystoscopy may aid in the acute diagnosis of
bladder injury and placement of a urinary Foley catheter.
• Nonoperative [Conservative] management-
• An 18–22 French bladder catheter for free drainage for the adult.
• Left indwelling for 10–14 days
• Cystogram to confirm cessation of extravasation prior to removal.
• After this period, more than 85% of bladder injuries will show absence of
extravasation.
• If extravasation persists, another 7–10 days of catheter drainage followed by
repeat cystography is done.

65. Bladder Trauma- Management

66. Bladder Trauma-
Management
• Intraperitoneal ruptures of the
bladder are uniformly managed
with operative repair.
• Such injuries typically result in
large, stellate tears in the dome
of the bladder.
• The edges of the bladder
laceration may require minimal
debridement to remove
devascularized tags of detrusor
muscle or mucosa.

67. Bladder Trauma- Management
• The laceration is then closed using two layers of heavy absorbable suture.
• Inner layer continuous 2-0 absorbable suture with outer layer imbricating
suture using 2-0 absorbable material.
• An adequate bore bladder catheter is used to allow for first few days.
• Duration of catheterization time is usually 5–10 days .
• Do a cystogram prior to removal of the catheter following any operative
repair.
• Suprapubic cystostomy catheters are not generally needed after repairs of
intraperitoneal ruptures. [AUA Guideline Statement 18 ]

68. URETHRAL INJURY
• Second most common injury in genitourinary tract
after renal trauma.
• Vulnerable to injury - pubic bones and the
puboprostatic ligaments.
• In men, anterior urethra is also susceptible to direct
trauma from bone fragments arising from the pubic
rami.
• Most common injury - Posterior urethra. Occurs
3%–25% with pelvic fractures.
• Most common associated mechanisms – RTA and
FFH.
• Upto 20% of patients with this type of injury have
an associated bladder laceration.
Mattox Trauma 8th Ed

69. Urethral
Injury-
Posterior Urethral Injury
•(Prostatic and membranous
part)
• Above Urogenital
diaphragm
Anterior Urethral Injury
• (Bulbous and penile part)
• Below the Urogenital
Diaphragm
URETHRAL INJURY

70. URETHRAL INJURY
Mechanism of Injury
• MCC is RTA and FFH.
• For posterior urethral injury “Straddle fractures” involving all
4 pubic rami and are associated with the highest risk of
injury.
• Commonly termed as Pelvic Fracture Urethral Distraction
Defects (PFUDD)
• Posterior urethra is densely adherent to the pubis via the
urogenital diaphragm and the puboprostatic ligaments, the
bulbomembranous junction is more vulnerable to injury
during pelvic fracture.
• Upto 20% of patients with this type of injury have an
associated bladder laceration.

71. URETHRAL INJURY
Mechanism of Injury
• MCC is RTA and FFH.
• For anterior urethra most occur after straddle
injury and involve the bulbar urethra, which is
susceptible to compressive injury because of its
fixed location beneath the pubis.
• A smaller percentage of injuries to the anterior
urethra are the result of direct penetrating injury
to the penis.

72. URETHRAL INJURY
• Symptoms-
• Triad of-----------------------------------------
• Presence of a perineal hematoma.-
”Butterfly Hematoma”
• Inability to clearly palpate the
prostate on rectal examination should
make one suspicious of urethral
injury- “High Riding Prostate.”
• Female patients presents with vulvar
edema, blood at the vaginal introitus .
Blood appearing at
the urethral meatus
Inability to urinate
Palpable distended
urinary bladder
Triad

73. AAST GRADING OF URETHRAL INJURY

74. URETHRAL INJURY- Management
• RGU should be performed before inserting a
urinary catheter when a urethral injury is
suspected.
• 8 Fr urinary catheter secured in the meatus by
balloon inflation to 1.5 to 2 mL.
• Approximately 30 to 35 mL of undiluted contrast
material is instilled with gentle pressure.
• In males, a radiograph is taken with an anterior-
posterior projection and with slight stretching of
the penis toward one of the patient’s shoulders
30 degree oblique position bottom leg flexed at
the hip and the knee.
• An adequate study shows reflux of contrast into
the bladder.

75. URETHRAL INJURY- Management
• General Points-
• Goal- Prompt urinary drainage in patients with
pelvic fracture associated urethral injury [PFUDD].
(Guideline Statement 20 -Evidence Strength: Grade C ).
• If the RUG reveals minimal extravasation of
contrast past an anterior injury and passage into
the proximal urethra and bladder- a single attempt
at gentle passage of a bladder catheter can be
performed.

76. • Management of Posterior Urethral Injury-
• Immediate suprapubic tube placement remains the standard of care
in men .
• In cases of female, most authorities suggest immediate primary
repair, or at least urethral realignment over a catheter, to avoid
subsequent urethrovaginal fistulae or urethral obliteration.
(Campbell Walsh Urology)
• Definitive Surgery- After 3-6 months Open posterior urethroplasty
(Bulbomembranous anastomosis) through a perineal anastomotic
approach is the treatment of choice.
URETHRAL INJURY- Management

77. PFUDD- Management
• The management of disruption or distraction
injuries of the posterior urethra remains
controversial.
• Techniques includes, endoscopic guidance,
open surgical approaches.
• A potential advantage of endoscopic
realignment is the possibility that the injury will
heal free of intractable stricture.

78. • Diversion with a SPC followed by a period of
observation of 3–6 months while the pelvic
hematoma resolves and the anatomy
stabilizes.
• Repeat AGU & RGU are then performed to
identify and localize and know length of
urethral loss.
• Definitive surgery- Bulbo-Membranous
anastomosis via Perineal approach.
PFUDD- Management

79. URETHRAL INJURY- Management

80. URETHRAL INJURY
Management
• Management of Anterior Urethral injury-
• Complete ruptures of the anterior urethra from
blunt trauma are best managed with suprapubic
diversion for greater than or equal to 3 months,
followed by elective end-to-end urethroplasty
when the perineal hematoma and induration
have fully resolved.
• Penetrating injuries to the anterior urethra may
be managed with local exploration and repair or
with suprapubic diversion.
• Extensive loss of the urethra from penetrating
trauma or industrial trauma may require a staged
repair.

81. Complications-
• PFUDD-
• Erectile Dysfunction
• Restenosis- Do DVIU
• Rarely Incontinence
• Anterior Urethral Injury
• Urethral Stricture
URETHRAL INJURY- Management

82. Finishing up the scenarios

83. Clinical Scenarios-Renal Injury
•Scenario- 1 –
• A 47-year-old man who sustained a high-impact injury in a road
traffic accident and had ongoing left loin pain and gross
hematuria on admission.
• He was hemodynamically stable
• He had # left 12 and 11th rib with a substantial bruise locally over
left flank with abrasion.
• On exam he had a ballotable tender lump left flank
Case Rep Urol. 2012; 2012: 207872

84. Cont..
• Clinical Scenario- 1
• He was, haemodynamically stable.
• CECT W/A IV only- revealed a Grade 3 renal injury on the left side and
a congenitally hydronephrotic right kidney. He was managed
conservatively on Surgical HDU and subsequently on the urology ward
with fluids and blood products as required.
• He improved gradually and repeat CECT showed stable hematoma
and was discharged after 12 days.

85. Clinical Scenarios-Ureteric Injury
•Scenario- 2-
• A 34-year-old woman was transferred to ER from another hospital after
removal of a knife from the RUQ of her abdomen. She complained of tenderness
in the entire abdomen. Her initial vital signs were stable, a 5-cm laceration in her
abdominal RUQ. Laboratory examination results were wnl except for TLC of
20,890/mm3.
• She had persistent hematuria and right hip irritation with difficulty
straightening right hip

86. Cont.
• Clinical scenario- 2- Ureteric Injury
• An abdominal (CT) scan showed a hematoma around the site of the stab
wound and right psoas muscle .
• A simple abdominal radiograph at the bed-side was performed 15 min after
the CT scan, which showed leakage of contrast material around the right
ureter.
• An emergency laparotomy was performed. There was a ureter injury of
nearly 50% of the ureter circumference was detected around the right
psoas muscle, causing a hematoma.
• An uretero-ureterostomy was performed after stenting of the ureter with
ureteral catheter.

87. Clinical Scenarios-Urinary Bladder
• Scenario- 3-
• A 29-year-old woman presented to the ER following a RTA. Gradually she developed
severe lower abdominal and flank pain, gross hematuria, and appeared lethargic
and confused, but had not experienced head trauma during the collision.
• She was afebrile, tachycardic, with normal BP. Her abdomen was distended and
guarded with rebound tenderness.
• There was frank blood at the urethral orifice and introduction of a bladder catheter
yielded no urine.
• Plain radiographs of the pelvis revealed no evidence of fracture. Laboratory data
were significant for a hemoglobin of 12.0 mg/dL, leukocytosis of 15.1 x 103 WBC/μL,
and elevated serum creatinine of 1.57 mg/dL.
• Int J Surg Case Rep. 2019; 55: 160–163

88. Cont.
Clinical Scenario-3
• CECT IV only revealed a moderate amount of simple fluid density ascites
within the abdomen and pelvis of unknown etiology .
• CT Cystogram revealed a full-thickness rupture across the bladder dome
• Trauma surgery then performed an emergent exploratory laparotomy.
Approximately one liter of clear urine was drained from the abdomen. The
bladder was repaired in two layers with absorbable sutures and a bladder
catheter was left in place. The bladder repair was then tested
intraoperatively by filling the bladder with fluid via the bladder catheter
until the bladder distended and no leak was observed.

89. Clinical Scenarios- Urethral Injury
• Scenario- 4-
• A 46 yr old man following an RTA presented with acute retention of urine with
blood at urethral meatus with hypogastric lump with pelvic pain and inability to
move right lower limb.
• Upon further investigation he was found to have a Type A open book pelvic
fracture with right intertrochanteic fracture with bp 92/66, hr-108/min, hb-8.9
gm/dl with tlc-13400/dl.
• The RGU shows abrupt cut off of dye in penile urethra with pie In the sky bladder.

90. Cont.
• RGU & MCU done and shows high riding bladder with abrupt cut off
of dye in bulbo-membranous junction
• Emergent Supra pubic cystostomy done for urinary diversion
• The pt underwent ORIF of right IT # with DHS fixation.
• Pt was kept in follow up for 5 months.
• Following that A staged Bulbomembranous grafting was done and
PUC kept in situ.

91. Take Home Message
• GU Injury, though rare, is significant source of morbidity and mortality
in patients with thoracoabdominal trauma.
• Renal trauma is most common among GU Injuries and most injuries in
haemodynamically stable patients are generally of low grade and
Non-operative management is the way to go with strict watchfulness.
• Urethral injury are 2nd most common injury and RGU is of utmost
importance before urethral cannulation and standard of care is
emergent SPC. Reconstructive surgeries are delayed unless in
females. Associated pelvic # needs simultaneous orthopedic
management.

92. Take Home Message
• Bladder injuries are most commonly associated with pelvic fractures.
• While the extraperitoneal bladder injuries obviates operative
management the Intraperitoneal ruptures are sure shot indication for
surgical exploration and repair.
• SPC may or may not be kept along with PUC and before
decannulation Cystogram is beneficial.
• Ureteric injuries are rarest, hard to diagnose, often associated with
significant other injuries, and need high index of suspicion and almost
always needs operative management upon detection.