This document discusses genitourinary trauma, focusing on injuries to the upper and lower urinary tract. It covers the etiology, clinical findings, imaging, and management of renal injuries, ureteral injuries, and bladder injuries. Renal injuries are the most common genitourinary injuries and are often caused by blunt trauma from motor vehicle accidents. Contrast-enhanced CT is the preferred imaging method to evaluate renal injuries. Most renal injuries can be managed non-operatively with bed rest and IV fluids, while operative management is indicated for persistent bleeding or expanding hematomas.

1. Genitourinary Trauma
10th Jan, 2013
By : Ext. Sirada Chittiwan
Ext. Jaipisut Rattanakajornsak

2. Introduction
• 10-20% of all injured patients
• Kidney : The most common
• Life-threatening injuries first
A: airway with cervical spine protection
B: breathing
C: circulation and control of external bleeding
D: disability or neurological status
E: exposure (undress) and environment
(temperature control)

3. Content
• Upper Urinary tract trauma
 Renal injuries
 Ureteral injuries
• Lower Urinary tract trauma
 Bladder injuries
 Urethral injuries
• External Genitalia injuries

4. Upper
Urinary tract trauma

5. Renal Injuries

6. RENAL INJURIES : Etiology
• The most common of all injuries to the GU
system
• Blunt trauma 80-85%
– Motor vehicle accidents, fights, falls, contact sports
– Vehicle collision at high speed : rapid deceleration
, major vascular injury
• Penetrating : Associated abdominal visceral injuries 80%
- Gunshot wounds
- Stab wounds

7. Mechanism of Renal Injuries

8. Clinical findings
• Pain : localized to one flank area or over the
abdomen
• Gross or microscopic hematuria
• Ecchymosis in the flank or upper quadrants of
the abdomen
• Lower ribs or transverse process fracture
• Palpable mass : large retroperitoneal hematoma
or urinary extravasation
• Generalized peritonitis

9. American Association for Surgery of Trauma
Organ Injury Severity Scale for the Kidneys
Classification

11. Indications for Renal Imaging
• Blunt trauma with gross hematuria
• Blunt trauma with microscopic hematuria and
shock (SBP < 90 mmHg anytime)
• Penetrating injuries with any degree of hematuria
• Pediatric patients (< 16 years)
• suspected any possible renal injury (e.g. patients
sustaining blunt trauma from rapid deceleration )

12. Imaging studies
• Contrast-enhanced CT -- preferred
• Single-shot intraoperative excretory urography
• Arteriography
• Sonography

13. Imaging Studies : Contrast-Enhanced CT
The preferred imaging study;
• Parenchymal lacerations
• Extravasation of contrast-enhanced urine
• Associated injuries
• Degree of retroperitoneal bleeding
• Lack of uptake of contrast material in the
parenchyma suggests arterial injury

15. Findings on CT that suggest
Major injury
(1) medial hematoma : suggesting vascular injury
(2) medial urinary extravasation : suggesting renal
pelvis or ureteropelvic junction avulsion injury
(3) lack of contrast enhancement of the
parenchyma : suggesting arterial injury

16. Single-shot intraoperative IVP
• Only a single film is taken 10 minutes after
intravenous injection (IV push) of 2 mL/kg of
contrast material
• If findings are not normal or near normal, the kidney
should be explored to complete the staging of the
injury and reconstruct any abnormality found

17. Arteriography
• To define arterial injuries suspected on CT
• To localize arterial bleeding that can be controlled
by embolization

18. Sonography
• Immediate evaluation of injuries
• Confirms the presence of two kidneys
• Can easily define any retroperitoneal hematoma
• Cannot clearly delineate parenchymal lacerations
and vascular or collecting system injuries
• Cannot accurately detect urinary extravasation in
acute injuries

20. MANAGEMENT
• Nonoperative Management
• Operative Management

21. Nonoperative Management :
Isolated Renal Injuries
• Approximately 80% to 90% of renal injuries have
major associated organ injury
• Blunt trauma can be managed nonoperatively
• Patients with grade IV parenchymal lacerations can be
observed expectantly
• Complete bed rest
• IV fluid replacement
• ATB prophylaxis
• Analgesic and Sedation
•TT prophylaxis

22. Operative Management
• Absolute indications
– Evidence of persistent renal bleeding
– Expanding perirenal hematoma
– Pulsatile perirenal hematoma
• Relative indications
– Urinary extravasation
– Nonviable tissue
– Delayed diagnosis of arterial injury
– Segmental arterial injury
– Incomplete staging

23. Renal Exploration
Surgical exploration of the
acutely injured kidney is best done by
Transabdominal approach
allows complete inspection of
intra-abdominal organs and bowel

24. Surgical Approach to
the renal vessels and kidney

25. Renal Reconstruction

26. Technique for Renorrhaphy

27. Renovascular Injuries

29. Indications for Nephrectomy
• Unstable patient, with low body temperature and
poor coagulation
• Extensive renal injuries when the patient’s life
would be threatened by attempted renal repair

30. Complications
• Urinoma – internal ureteral stent
• Perinephric abscess – percutaneous
draingage, surgical drainage
• Delayed renal bleeding
– Usuall occurs within 21 days
– Angiography and embolization
• Hypertension

31. Arterial Hypertension
• Renal vascular injury, leading to stenosis or
occlusion of the main renal artery or one of its
branches
• Compression of the renal parenchymal with
extravasated blood or urine
• Post-trauma arteriovenous fistula

34. Ureteral Injuries

35. URETERAL INJURIES : Etiology
• External Trauma (20%)
- After external violence are rare (<1%)
- 10 - 28% have associated renal injuries
- 5% have associated bladder injuries
• Surgical Injury (80%)
– Pelvic surgical procedure (M/C: Hysterectomy)
– Endoscopic manipulation, etc.

37. Clinical findings
• Post operative fever
• Flank and lower quadrant pain
• Paralytic ileus with nausea and vomitting
• Peritonitis
• Uretervaginal fistula
• Ureterocutaneous fistula
• Hematuria

38. American Association for the Surgery of Trauma
Organ Injury Severity Scale for the Ureter

39. Imaging Studies
• Excretory Urography : intraoperative one-shot
pyelography
• Computed Tomography - IVP
• Retrograde Ureterography
• Antegrade Ureterography : If retrograde stent
placement is not possible

40. Imaging findings
• Excretory urography
– Delayed function
– Hydronephrosis
– Extravasation
• Retrograde
ureterography
– Demonstrates the exact
site of obstruction or
extravasation

41. Treatment
• Repair when injury occurs
– Before 7 days  immediate Reexploration and
repair
– Delayed diagnosis  nephrostomy + repair after
3 months
Goals of ureteral repair
– Complete debridement, tension-free spatulated
anastomosis, watertight closure, ureteral
stenting, retroperitoneal drainage