Trauma, 7th Ed.

CHAPTER 36. Genitourinary Trauma

Michael Coburn

Genitourinary injury occurs in 2–5% of all trauma patients and in at least 10% of patients with abdominal trauma, emphasizing the need for a close collaboration between the general and urologic trauma surgeon. This unique relationship that the urologist and general trauma surgeon share in the management of urologic injuries requires that common philosophies of management be applied.

Controversies exist in the approach to urologic trauma, and recent efforts to achieve a broad consensus in the management of diverse urologic injuries have resulted in numerous publications. One such effort, sponsored by the World Health Organization and the Societe Internationale d’Urologie, involved a 25-year review of world literature focusing on levels of evidence and development of evidence-based management recommendations.15 Another similar effort through the European Association of Urology (EAU) had a similar focus.6 Both produced useful syntheses of a large body of literature. The current discussion will offer a broadly applicable approach to the management of urologic trauma based on current literature and local experience and perspective.

ANATOMY

Beginning with surgical exposure for upper tract injuries, the contemporary approach to the injured kidney is through an anterior midline abdominal incision. Access to the kidneys and ureters is generally obtained by reflecting the colon on either side medially and exposing Gerota’s fascial envelope. While modern descriptions of exposing the injured kidney often involve a discussion of first obtaining vascular control of the renal vessels prior to entering the perirenal hematoma, the important element in this practice is achieving access to the pedicle such that atraumatic vascular clamping can be achieved if significant bleeding is encountered. This can be accomplished through individually dissecting and “looping” the renal vessels through an incision in the posterior peritoneum over the aorta (which can allow access to either the left- or right-sided artery and the left-sided vein) or by first reflecting the colon on the side of injury and then obtaining vascular control or access to the pedicle. Obviously, the renal vessels should be approached first and dissected directly when there is suspicion of a renovascular injury (medial or perihilar hematoma, pulsatile hematoma). When suspicion of a renovascular injury is low, many urologic trauma surgeons successfully approach the kidney by first reflecting the colon and then achieving vascular control. This is achieved by individually dissecting the vessels, by using a vascular pedicle clamp, or through digital compression.

The kidney is located high and posteriorly in the retroperitoneum. The midline incision may need to be extended to the xiphoid process and additional upper abdominal retraction inserted for proper exposure. The kidney overlies the diaphragm, transversus abdominis aponeurosis, and quadratus lumborum muscle laterally and psoas major muscle medially. Significant bleeding from these muscles and the deep muscles of the back can occur following penetrating trauma and may confuse the picture in which brisk bleeding is occurring in the renal fossa. The kidney is enclosed in a thin but strong fibrous capsule, which should be left intact during renal dissection and mobilization. As the capsule is usually lifted off the parenchyma by an underlying hematoma, the entire capsule may inadvertently be stripped off the kidney by the sweeping finger used to quickly elevate the kidney into the wound. Ideally, the kidney should be mobilized through sharp and blunt dissection working from a normal area toward the area of parenchymal injury to keep the capsule on the kidney. Stripping the capsule complicates the repair of the kidney and should be avoided.

Recognizing patterns of injury is important, and the trauma surgeon should anticipate injuries to adjacent organs based on the relational anatomy of the kidney and ureter and the trajectory of a penetrating injury7 (Fig. 36-1). The left kidney is crossed anteriorly in its upper portion by the tail of the pancreas and lies behind the lower portion of the spleen. On the right, the duodenum is immediately anterior to the hilar region. In the setting of a renal injury on the right side, the right colon, liver, and duodenum are commonly injured in penetrating trauma. With blunt trauma, an associated hepatic laceration is most common. On the left side, injuries to the left colon, stomach, spleen, and pancreas are common in penetrating trauma. And lacerations of the spleen are particularly common with blunt trauma to the left upper quadrant. Injuries to the diaphragm are also common with penetrating renal injury and less common with blunt injury. The left adrenal gland is located medial to the upper pole of the left kidney, while the right adrenal gland is located in a more cephalad position relative to the right upper renal pole and may be in a retrocaval position.

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FIGURE 36-1 Renal anatomy: relational anatomy of the kidney. Note proximity of great vessels, duodenum, liver, spleen, pancreas, and colon, relevant to predicting patterns of injury and likely sites of concomitant organ injury in renal trauma.

At the level of the renal pedicle, there are most commonly single renal arteries and veins present bilaterally. The renal vein, artery, and renal pelvis are organized in an anterior-to-posterior orientation. On the right side, the gonadal vein arises from the vena cava at or slightly below the level of the renal pedicle. A lumbar vein, which may be quite large, often arises from the posterior aspect of the right renal vein, near the insertion with the inferior vena cava. The right adrenal vein enters directly into the vena cava, often on its posterolateral aspect. On the left, the main branches of the renal vein include the left gonadal, the adrenal, and one or more lumbar veins. This asymmetry of the collateral branches of the renal veins explains why the left renal vein can be safely ligated near the vena cava, with an 85% chance of renal preservation. In contrast, the right kidney will most likely develop venous thrombosis and become nonviable if the right renal vein is ligated.

For the urologic trauma surgeon who engages in intrarenal surgery and renal reconstruction, knowledge of the intrarenal anatomy is important (Fig. 36-2). The renal arterial supply consists of the following five segments: apical, superior (anterosuperior), middle (anteroinferior), lower (inferior), and posterior. The posterior branch crosses cephalad to the renal pelvis to reach its segment. About 25% of kidneys receive accessory arterial branches directly from the aorta. These may enter through the renal sinus or at the upper or lower poles. Certain anomalies of the upper urinary tract, such as horseshoe kidney and congenital obstructive and duplication types, must be familiar to the trauma surgeon, as they may impact management.

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FIGURE 36-2 Intrarenal vascular anatomy: vascular branches supplying various arterial segments of the renal parenchyma. Knowledge of intrarenal anatomy is critical to successful reconstructive efforts.

The blood supply to the ureter is particularly important in surgery for urologic trauma (Figs. 36-3 and 36-4). The main sources are the renal artery from above, the aorta or common iliac arteries, and the vesical arteries from below. Branches approach the upper and midureter primarily from the medial side, while in the lower pelvis, the blood supply to the ureter enters primarily from a lateral direction. These branches form a long, predictable anastomotic chain usually with a single longitudinal vessel that runs the length of the ureter, in the plane between the ureteral adventia and muscularis.

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FIGURE 36-3 The ureteral blood supply originates from branches of the adrenal and renal arteries in the upper third, branches of the aorta and gonadal arteries in the middle third, and the pelvic vessels as shown in the lower third. Knowledge of the ureteral blood supply and derangements due to preexisting pathology or prior surgery is important in maintaining ureteral viability during surgical mobilization and reconstruction.

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FIGURE 36-4 Ureteral anatomy: the longitudinal blood vessels run deep to the adventitial sheath; it is important to achieve a dissection plane superficial to this layer to avoid devascularization of the ureter during surgical mobilization.

Anatomy of the urethra, perineum, and external genitalia may be less familiar to the general trauma surgeon. The gross anatomy and fascial layers of the genitalia and perineum are important in trauma, as they largely determine the manner in which blood and urine extravasate following urethral or genital trauma (Fig. 36-5).

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FIGURE 36-5 Diagram of sites of extravasation, associated with urethral disruption. (A) With an intact Buck’s fascia, extravasation of blood and/or urine is isolated to the penile shaft. (B) With Buck’s facial defect, extravasation extends into the scrotal tissues and compartments.

INJURY GRADING AND SCORING SYSTEMS FOR GENITOURINARY INJURIES

The American Association for the Surgery of Trauma (AAST) Injury Scaling Committee has devised a staging system for urologic injuries. The system, originally published in 1989 and since amended, addresses injuries to the kidney, ureter, bladder, urethra, testis, scrotum, and penis (Table 36-1).8 For some organs such as the kidney, the system has proven highly applicable and has come into common use. For other organs, such as bladder and ureter, the AAST system has been less commonly utilized for a variety of reasons, largely relating to lack of specificity of available imaging approaches to provide the necessary data for assignment of a grade. The grading systems for urethra and external genitalia are coming into more common use and are of value in addressing outcomes following such injuries. Several aspects of the staging system have received attention regarding their clinical significance and impact on decision making, complication rates, and patient outcomes.911

TABLE 36-1 Urologic Injury Scale of the American Association for the Surgery of Trauma

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As noted, the renal Organ Injury Scale utilizes five grades of injury, ranging from contusion or subcapsular hematoma (I) to shattered kidney or avulsion of the hilum (V) (Fig. 36-6). It is valuable to specifically distinguish the parenchymal lacerations from renovascular trauma in the group IV and V injuries when reporting experience, as management and outcomes differ between these entities. The varying degrees of renal injury as described in the scaling system are depicted diagrammatically in Fig. 36-6. Recent data have shown support for the clinical utility and validity of the renal injury scale, indicating that this system is predictive of morbidity in blunt and penetrating renal injury, of mortality in blunt injury,10 and of the risk of nephrectomy with exploration for renal trauma.

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FIGURE 36-6 Organ injury scaling system for renal trauma.

As the percentage of the circumference of the ureter that has been disrupted is difficult to determine from imaging studies, the ureteral scaling system is mainly amenable to the operative setting. For the bladder, the distinction of intraperitoneal from extraperitoneal rupture is important and is addressed in the scaling system, but whether the length of the laceration in the bladder wall truly has clinical significance has not been demonstrated. For urethral injuries, the scaling system addresses anatomic factors that can often be determined from retrograde urethrography (RUG) and provide advantages over the earlier system described by Calopinto and McCallum.12 The current AAST system addresses urethral disruption based on whether the injury is complete or incomplete (i.e., whether contrast enters the bladder) and on the length of the urethral defect and presence of extension into prostate or vagina. Endoscopic assessment indicates that in some cases where the retrograde urethrogram would suggest a complete disruption, partial circumference continuity does exist, at times allowing for insertion of a catheter into the bladder. Nevertheless, despite some lack of specificity, the AAST organ injury scaling system has substantial usefulness.

The scaling system for organ-specific injuries as applied to genitourinary trauma (Tables 19-22 and 29-31 from AAST Web site) has introduced a needed advance in the field.8 The designations of the AAST system should be utilized whenever possible in clinical descriptions and published work on urologic trauma.

CLINICAL PRESENTATION AND DIAGNOSIS OF RENAL TRAUMA

Image Incidence and Patterns of Injury

Renal injuries occur in approximately 1–3% of all trauma patients and up to 10% of patients with abdominal trauma. The percentage of blunt and penetrating trauma varies dramatically depending on the health care institution and the population served. In some urban trauma centers, penetrating injuries predominate,7,1315 although overall, approximately 90% of significant renal injuries are due to blunt trauma in the United States.16

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.

Kidneys with preexisting anatomic abnormalities appear to be more vulnerable to significant injury from seemingly minor blunt trauma.17,18 Such entities would include obstruction of the ureteropelvic junction, large cystic lesions, and renal neoplasms. Injuries to nonurologic structures in the abdomen are found in approximately 20–33% of patients with blunt renal injuries.

Image Clinical Presentation and Evaluation

A history of a blow to the flank, deceleration trauma, fall from a height, or penetrating abdominal, pelvic, and lower chest injuries should raise the possibility of a renal injury. Hematuria is the most common sign of renal trauma, although the magnitude of the hematuria correlates poorly with the magnitude of injury.

Physical examination in patients at risk for renal injury should include careful assessment of the abdomen, back, flank, and chest, along with a complete genitourinary examination. Findings suggestive of a renal injury include tenderness in the flank, costovertebral angle or abdomen, a palpable flank mass, or ecchymosis in the flank, back, or abdomen. Complete inspection of the trunk for a penetrating injury is critical. Stab wounds posterior to the anterior axillary line carry a risk of renal injury, with only about 12% of such injuries being associated with injury to another organ.

Laboratory assessment should include urinalysis by dipstick, as well as microscopic examination for blood or infection. The first specimen in the emergency center should be analyzed for hematuria to optimize diagnostic accuracy. Determination of serum electrolytes, blood urea nitrogen (BUN) and serum creatinine, and hemoglobin is important. A blood sample for type and screen or cross-match should be obtained when clinically appropriate.

Image Radiographic Imaging for Renal Trauma

Traditionally, all patients with abdominal trauma and any degree of hematuria were imaged in the emergency center on presentation. Using this approach, some series of renal trauma have shown that greater than 90% of imaged patients will have only minor injuries, primarily contusions or other minor injuries not requiring intensive monitoring or intervention. With an eye toward cost-effectiveness and minimizing the time and potential morbidity of unnecessary imaging, several groups have assessed the safety and feasibility of establishing more selective approaches toward renal imaging in the trauma setting.19 The disadvantages of imaging include expense, radiation exposure, possible allergic or nephrotoxic reactions to contrast, time expenditure, and the risk of moving the patient. These factors need to be balanced against the risk of missed injuries with a resultant delay in diagnosis. In 1985, the group from San Francisco General Hospital analyzed their renal trauma experience and found that the only findings that were predictive of significant renal injury were the presence of penetrating trauma, or blunt trauma with gross hematuria or with microhematuria and shock. Shock was defined as a systolic blood pressure <90 mm Hg at any time postinjury, including during transport by EMS. In a review of 812 patients with microhematuria but without shock, no significant renal injuries were detected. All 44 injuries in this original series were found among the 195 patients with gross hematuria or microhematuria and shock. This series has been extended over the years such that in the expanded patient group of 2,254 patients with renal trauma approximately one third were imaged and two thirds were not. Within this group, no major renal injuries were missed using the established criteria.2022

Other investigators have modified these imaging criteria according to their own experience and judgment. Some have suggested including standard imaging for patients with injury to the brain, loss of consciousness, or altered mental status, with the belief that the loss of information on a physical examination and the magnitude of trauma in such patients may create a higher risk of a missed injury. Some have suggested extending imaging indications to patients with mechanisms of injury consistent with deceleration trauma. This approach avoids missing injuries to the renal pedicle (e.g., intimal disruption in the renal artery and renal devascularization), which may present with no hematuria in 20–33% of patients. The presence of fractures of long bones, fractures of the lower ribs, or fractures of transverse spinous processes has also been suggested as an indication to modify the previous imaging restrictions, possibly predicting a higher risk of occult renal injury. In the pediatric population (addressed in Section “Pediatric Renal Trauma”), imaging for patients with only microhematuria has been more liberally utilized.

As noted, the criteria involving limiting imaging to patients with gross hematuria or microhematuria with shock have not been extended to those with penetrating trauma. Patients with penetrating trauma with any degree of hematuria, injury proximity, or suspicion are appropriate candidates for imaging of the urinary tract, regardless of the presence or magnitude of hematuria. Significant penetrating injuries can present without hematuria, particularly if trauma to the major collecting system causes all urine from the injured kidney to exit into the retroperitoneum, preventing ureteral peristalsis.

In penetrating trauma, imaging would generally be obtained in assessing a patient’s candidacy for nonoperative management in the appropriate clinical setting. The concept of obtaining preoperative renal imaging simply to demonstrate the presence of two functioning renal units prior to surgical intervention has become less popular in recent years. Instead, careful intraoperative palpation of the kidneys and, on occasion, intraoperative intravenous pyelogram (IVP) may be used selectively during a trauma laparotomy to demonstrate renal presence or function.23 The selection of imaging modalities has evolved greatly since the advent and availability of computed tomography (CT) scanning to emergency center evaluation.19 While the bolus IVP with nephrotomography had in the past been the standard imaging approach, the CT scan has, over the years, become the gold standard for precise staging of renal injuries (Fig. 36-7), and has largely replaced intravenous pyelography in most clinical settings.

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FIGURE 36-7 Staging computed tomography scans for blunt renal injury. (A) Grade II injury: blunt trauma, small right posterior subcapsular and perirenal hematoma without obvious parenchymal laceration. (B) Grade II and III injury: blunt trauma, laceration posteromedially in left kidney without collecting system injury. (C) Grade IV parenchymal injury: blunt trauma, deeper laceration to right kidney, full-thickness parenchymal laceration with collecting system injury as indicated by contrast extravasation. Moderate-sized perinephric hematoma. No significant devitalized parenchyma noted.

Although the IVP had in the past been described as being accurate for clinical staging purposes in 60–85% of patients, CT scanning offers a number of important advantages.24 Nevertheless, trauma surgeons and urologists should remain familiar with the findings suggestive of renal injury on IVP, as routine use of CT for trauma assessment is not consistently available, especially when considering variations in international practice and infrastructure, and intraoperative IVPs may still be necessary at times. These IVP findings include the presence of a fracture of a transverse process on the scout film, presence of a mass effect in soft tissue, loss of the psoas margin on the involved side, and alteration of the longitudinal axis or vertical displacement of the kidney. Loss of a clear renal cortical outline, gross extravasation of contrast, ipsilateral decrease in renal excretory function, and loss of opacification of portions of the collecting system should all be noted. The IVP allows confirmation of the presence of two renal units, gives general information of the extent of injury, and may show significant extravasation.

Estimates of the accuracy of IVP in detection of renal injury vary. In general, the IVP should be viewed as a crude means of detection, rather than as a means to obtain precise staging. Some studies indicate that as many as 20% of patients with significant renal injuries may have a normal IVP. In addition, up to half of patients with reduced function or nonfunction of a kidney on IVP will have a reason for it other than arterial occlusion, including contusion, overhydration, and hypotension or hypoperfusion.

Advantages of CT over IVP include identification of contusion and subcapsular hematoma, definition of the location and depth of parenchymal lacerations, more reliable demonstration of extravasation of contrast, and identification of injuries to the pedicle and artery (“rim sign,” “cutoff sign,” etc.). There is also enhanced imaging of the perinephric space, other solid viscera (liver, spleen, pancreas), as well as delineation of many cases of perforation of a hollow viscus and identification of free intraperitoneal fluid. For these and other reasons, the contrast-enhanced CT scan has largely replaced the IVP for trauma imaging. With the current spiral CT scanners, sequences are so rapid that it is important to be sure that delayed, excretory images are obtained to avoid missing extravasation from the collecting system or ureter, which may not be apparent from early images alone.25

Arteriography has had less of a role in the staging of a renal injury since CT has become popular, especially considering its cost, invasiveness, and the special expertise required. As the use of CT for diagnosis of a pedicle injury has become standard, far fewer arteriograms are being obtained. Still, precise delineation of arterial anatomy and interventions for control of hemorrhage mandate the continued use of renal arteriography on a selective basis (Fig. 36-8). In Europe and other parts of the world, abdominal ultrasound has been extensively utilized in diagnosing and assessing blunt renal injury. In the United States and elsewhere the Focused Assessment for the Sonographic Evaluation of the Trauma Patient (FAST) study is performed to assess for free intraabdominal fluid rather than for the delineation of an injury to parenchyma of solid organs. The ability to apply high-resolution Doppler techniques to assess renal perfusion and vascular anatomy may extend the use of ultrasound for renal imaging in the future.

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FIGURE 36-8 (A and B) Renal artery occlusion due to intimal disruption following deceleration injury. Restrained driver in head-on motor vehicle collision. The left kidney is nonperfused and demonstrates minimal renal sinus vascular enhancement and cortical rim enhancement from capsular vessels. This finding is considered pathognomonic for this injury and does not require arteriographic confirmation unless the vascular surgeon believes further vascular imaging is necessary to plan therapy.

Retrograde pyelography plays a limited role in clearly defining anatomy of the ureter and collecting system when a pattern of medial extravasation or failure of ureteral opacification on CT or IVP is present.

PEDIATRIC RENAL TRAUMA

Some studies suggest that the pediatric kidney is more vulnerable to trauma than is the adult kidney.26 Reasons for this include the relatively larger size of the kidneys compared with the adult, the relative deficiency of perinephric fat in the child, and, probably, the higher incidence of preexisting renal abnormalities. One recent review found that 8.3% of pediatric renal injuries occurred in the setting of preexisting renal abnormality,17 with other estimates of preexisting renal abnormality described in as many as 23% of major pediatric renal injuries due to blunt trauma. Some data suggest that the kidney is the most commonly injured intra-abdominal organ in children.

It is nearly universally agreed that the presence of gross hematuria after trauma in the pediatric patient deserves further investigation with imaging of the urinary tract. As in the adult, the CT scan has the major role in staging such injuries for the same reasons as described earlier. Several studies suggest that only about 5% of pediatric patients with major renal injuries will develop signs of shock, further emphasizing the importance of an aggressive diagnostic approach. Pediatric patients can maintain a normal blood pressure despite significant blood loss, and persistent tachycardia is a particularly important parameter to note in the pediatric patient as a potential sign of significant blood loss.

The currently accepted approach in the adult is not applied liberally in the pediatric setting. Many authors suggest that all pediatric patients with any degree of hematuria after significant trauma should undergo renal imaging, while some have suggested modified criteria. One study has suggested that microscopic hematuria with greater than 50 red blood cells per high-power field in the pediatric setting should be considered an imaging criterion, regardless of hemodynamic parameters.27

Certain types of renal injuries are clearly more common in the pediatric patient. These include laceration of the renal pelvis, avulsion of the ureteropelvic junction, and forniceal avulsion. When extensive medial extravasation is noted and/or the ureter does not opacify with contrast despite adequate excretion into the renal collecting system, a disruption of the major collecting system should be considered. In such cases, retrograde pyelography may be necessary to clarify the anatomy and achieve a diagnosis.

As in the adult, the use of the rapid spiral CT scanner can lead to a pitfall in diagnosis if a delayed sequence is not requested. Limiting the study to a nephrographic or early excretory phase may fail to demonstrate extravasation or asymmetrical opacification of the ureters, which would be readily visible on later images.

Overall, approximately 85% of pediatric renal injuries from blunt trauma are minor (contusions, superficial parenchymal lacerations) and are managed with bed rest and observation. Pedicle injuries comprise about 5% while major parenchymal injuries occur in 10–15% of patients. As in the adult, it is these latter groups for which management is somewhat controversial; however, it is largely agreed among pediatric urologists that operative decisions are based mainly on hemodynamic status rather than imaging criteria. The potential for successful management of kidneys that look very severely injured on imaging studies is remarkable in the pediatric population, and a nonoperative approach is the norm. Surgical treatment is generally reserved for patients with ongoing bleeding or hemodynamic instability, for those who have clearly failed an attempt at nonoperative management, and for penetrating injuries.28

CLINICAL PRESENTATION AND DIAGNOSIS OF TRAUMA TO THE URETER, BLADDER, URETHRA, AND EXTERNAL GENITALIA

Image Ureter

Ureteral injuries are relatively uncommon, occurring in approximately 4% of patients with penetrating abdominal injuries and in less than 1% of those with blunt abdominal trauma. Concomitant visceral injury occurs in the majority of patients with ureteral injuries from penetrating trauma. While hematuria is an important sign of ureteral injury, it may be absent 15–45% of the time. As such, a high index of suspicion for ureteral injury is critical.2932 In fact, ureteral injury is one of the most common sites of missed injury at laparotomy, with one recent report noting a missed injury rate of 11% (15). While direct visualization of the ureter is the mainstay of detection of ureteral injury at the time of laparotomy, imaging modalities useful for detection of ureteral trauma include an IVP and contrast-enhanced CT scanning.16 Modern spiral scanners move rapidly through the abdomen following administration of contrast, and, unless a delayed excretory phase is specifically requested, extravasation may be missed as previously described. Failure of the distal ureter to opacify on a CT scan should raise concern of an injury.3335 When noninvasive imaging fails to provide sufficient detail regarding ureteral anatomy or the specific nature of an injury, cystoscopy with retrograde pyelography may be indicated.

Image Bladder

Sudden compression of the full bladder, shear forces, or a pelvic fracture may result in a blunt rupture. Rupture may be accompanied by lower abdominal pain, by an inability to void, and by suprapubic or perineal ecchymoses. The cardinal sign of injury to the bladder is gross hematuria, present in greater than 95% of cases, while only about 5% of patients will have microscopic hematuria alone.36 Over 80% of patients with a bladder rupture have an associated pelvic fracture in centers with a high percentage of blunt trauma. An association of bladder rupture with disruption of the posterior urethra, also in the setting of pelvic fracture, may occur in 10–20% of patients.37,38 Overall, recent data indicate that genitourinary injury occurs in approximately 15% of pelvic fractures in the pediatric setting17 and that the incidence of injury to a pelvic organ is fairly comparable between adult and pediatric patients.39,40

Stress cystography is the standard study for diagnosis of injury to the bladder (Fig. 36-9).41 It is important that the bladder be adequately filled to avoid false-negative studies. For the adult bladder, 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. If the patient is obtunded or unable to indicate that there is a sense of fullness, using a standard filling volume is a useful methodology. A filling film is obtained that should be a vertically oriented abdominal image designed to show the entire abdomen. Patterns of contrast extravasation have been described for intraperitoneal, extraperitoneal, and combined ruptures (Fig. 36-10). Hematuria of bladder origin without contrast extravasation on a properly performed stress cystogram is consistent with a contusion or minimal mucosal injury, which is uniformly managed nonoperatively. Postdrainage washout films are generally recommended to avoid false-negative cystograms in which extravasated contrast may be missed if located only anterior or posterior to the distended bladder on an anteroposterior film.

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FIGURE 36-9 (A and B) Stress cystogram: through Foley catheter, the bladder is filled by gravity to a standard volume (300–400 mL typically in adult), or to the point of perceived fullness by patient. Plain radiograph obtained to allow visualization of upper and lower abdomen, followed by washout film.

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FIGURE 36-10 Bladder: stress cystograms for assessment of suspected bladder injury following blunt trauma to pelvis. (A) Stress cystogram in patient with gross hematuria and pelvic fracture, demonstrating adequate bladder filling and typical pattern of extraperitoneal extravasation—flame-shaped contrast density lateral to right lower bladder segment. Injury managed successfully with 10 days of catheter drainage. (B) Washout phase following stress cystogram. Extraperitoneal extravasation pattern noted in right hemipelvis. Washout films may reveal extravasated contrast anterior or posterior to the contrast-filled bladder, which can be missed on films obtained when the bladder is filled with contrast. (C) Lateral compression of bladder from pelvic hematoma, along with extraperitoneal extravasation pattern in right pelvis, on an incomplete washout film. (D) Intraperitoneal bladder rupture. Note extravasated contrast outlining colic gutters, surrounding loops of small bowel, and occupying cul-de-sac in pelvis, indicative of intraperitoneal contrast. (E) Intraperitoneal bladder rupture. Again, note contrast in pelvis and outlining of right colon and small bowel in pelvis. Cystograms following penetrating pelvic trauma with hematuria. (F) Gunshot wound to pelvis in patient with microscopic hematuria. Bladder is intact, but is displaced to right due to large, left-sided pelvic hematoma. Obturator vessel injury noted; vessels ligated following evacuation of hematoma at laparotomy and pelvic exploration. (G) Gunshot wound to bladder with intravesical clot creating filling defect in bladder. Bladder incompletely filled; extravasation noted on subsequent film, following optimal filling of bladder.

Currently, stress cystography is most commonly obtained using a CT technique (Fig. 36-11).42 The same general principles apply as for static cystograms (i.e., adequate bladder filling is essential to avoid missed injuries) (Fig. 36-11B and C). Studies comparing the accuracy of standard radiographic stress cystography with CT cystography suggest equivalent capability in defining and staging bladder injuries, while the CT cystogram provides enhanced information regarding the perivesical space and adjacent structures. Simply clamping a bladder catheter following intravenous contrast administration, with the expectation that passive filling with contrast-opacified urine will suffice, is not adequate and will result in an unacceptably high percentage of false-negative examinations, with either the standard radiographic or the CT technique.42 In selected cases, flexible cystoscopy may aid in the acute diagnosis of bladder injury.43

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FIGURE 36-11 (A) Computed tomography (CT) cystogram demonstrating intraperitoneal bladder rupture. A standard stress cystographic technique has been employed, with instillation of 350 mL of contrast followed by scanning of upper, middle, and lower abdomen. Contrast is seen filling colic gutters and filling the true pelvis, in this case clearly outlining the ovaries. (B) False-negative CT cystogram. This image was obtained by clamping the indwelling Foley catheter and obtaining CT images of the pelvis with passive filling of the bladder following intravenous contrast administration. No extravasation is noted, but the bladder is not adequately filled to reliably exclude injury. A properly performed static cystogram following the CT revealed extensive intraperitoneal extravasation. Inadequate bladder filling is the most common reason for a false-negative cystogram. (C) Attempted CT cystogram following pelvic fracture in a 13-year-old male. Extravasation extends through the pelvic floor into the buttock, and no filling of the bladder is seen. The Foley balloon is actually positioned in the pelvic hematoma. The patient was found to have a bladder neck avulsion injury, which was initially managed with an open surgical cystostomy, and then surgically reconstructed 72 hours following injury.

Image Urethra

Trauma to the anterior urethra may result from straddle injuries with sudden compression at the level of the midurethra to deep bulbar urethra against the inferior pubic arch. Urethral distraction injuries, or posterior urethral disruption, may accompany pelvic fracture in 4% to >10% of patients. Bilateral fractures of the pubic rami, especially when accompanied by an open pelvic ring (abnormally distracted sacroiliac joint), may be present in patients who have suffered posterior urethral disruption as well. The classification system used to further describe urethral trauma is discussed in Section “Injury Grading and Scoring Systems for Genitourinary Injuries.” It is important to determine from the urethrogram if an injury is partial (contrast passes proximal to the point of extravasation filling the more proximal urethra or bladder) or complete (all contrast extravasates, and none enters the urethra proximal to injury or bladder), as this factor has an impact on selection of management.44

Blood appearing at the urethral meatus, inability to void, presence of a perineal hematoma, and inability to clearly palpate the prostate on rectal examination should make one suspicious of urethral injury (Fig. 36-12). When urethral injury is suspected, a retrograde urethrogram should be performed (Fig. 36-13). Approximately 30 mL of iodinated contrast is instilled via a catheter inserted just within the urethral meatus, at which point a plain radiograph is obtained. A normal retrograde urethrogram should demonstrate contrast filling an intact urethra and entering the bladder without extravasation. No attempt at insertion of a bladder catheter should be pursued until a negative retrograde urethrogram is obtained to avoid further complicating a urethral rupture (Fig. 36-14).

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FIGURE 36-12 Mechanism of anterior urethral disruption due to straddle injury; extravasation pattern and hematoma limited in this case by Colles’ fascia, due to rupture of Buck’s fascia along with full thickness of urethral wall. Hematoma and urinoma may extend along shaft of penis and into scrotum and perineum.

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FIGURE 36-13 Technique of retrograde urethrogram. Retrograde urethrogram: catheter is inserted into urethral meatus, with minimal balloon inflation to maintain position and allow hands to be out of x-ray field. Contrast is instilled to distend urethra.

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FIGURE 36-14 Urethra: posterior urethral disruption with pelvic fracture. (A) Retrograde urethrogram demonstrates extravasation of contrast both above and below urogenital diaphragm and no filling of prostatic urethra or bladder neck, consistent with complete disruption. Note pubic ramus fracture and marked cephalad elevation of bladder (bladder filling with contrast excreted following intravenous administration for computed tomography scan). Hemodynamically unstable patient required angiographic embolization for pelvic hemorrhage. Urethral disruption managed with open suprapubic cystostomy. (B) Combined antegrade and retrograde contrast studies 6 months postinjury, demonstrating obliterated posterior urethral distraction defect, in preparation for reconstructive surgery.

Following placement of either a urethral catheter (if the urethra proved normal or by a urologist using direct vision techniques in selected incomplete injuries) or a suprapubic catheter (if urethral disruption was revealed), a stress cystogram should still be performed if hematuria is present. This is because 10–15% of patients with urethral disruptions from a pelvic fracture will have a concomitant injury to the bladder.

Image External Genitalia

Genital injuries represent a diverse group of traumatic events.45 These include the classic blunt penile fracture (which occurs from forceful bending of the erect penis, often during intercourse), crush injuries with rupture of the testis, penetrating injuries, and industrial accidents. Amputation injuries of the penis or testicle can occur due to assaults, self-mutilation, or industrial trauma. After major blunt trauma to the scrotum, the risk of testicular rupture is approximately 50%. An ultrasound examination of the scrotum may be valuable to distinguish testicular rupture from a hematoma of the scrotal wall or hematocele (blood within the tunica vaginalis compartment).

NONOPERATIVE MANAGEMENT OF GENITOURINARY INJURIES

While nonoperative management for many urologic injuries has become well established, the selection of operative versus nonoperative management for certain genitourinary injuries remains controversial. Recent reviews of urologic management based on careful assessment of levels of evidence reveal a notable paucity of level 1, prospective management studies.16 The relatively recent efforts to accurately and uniformly describe and stage the nature of injuries and the lack of long-term follow-up leave many questions as to the best way to manage many forms of genitourinary trauma.

Image Kidney

It has long been accepted that low-grade renal injuries can be managed nonoperatively with a high success rate. Renal contusion and subcapsular hematomas are routinely managed expectantly and only rarely would surgical or other interventions be required in such cases. These injuries heal spontaneously with few exceptions as do low-grade parenchymal lacerations. Depending on the institutional bias and experience, some urologic trauma surgeons may limit operative management of renal injuries to those in which the patient is hemodynamically unstable, almost regardless of imaging findings. Alternatively, others would include those injuries in which the grade of injury is high, presumably translating into a higher incidence of postinjury complications with nonoperative management. A number of indications for renal exploration following injury have been suggested by McAninch and Carroll.46 These include hemodynamic instability, ongoing hemorrhage requiring significant transfusion, pulsatile or expanding hematoma on exploration, and avulsion of the pedicle. These strong indications for surgical or other procedural intervention remain widely accepted. Relative indications for surgical intervention have included high-grade injuries, large perirenal hematoma, presence of urinary extravasation on contrast studies, significant devitalized fragments of parenchyma, and findings in the operating room during laparotomy with an incompletely staged injury. While there is lack of consensus regarding these relative surgical indications, there is a general trend toward nonoperative management in many of these situations, as long as hemodynamic stability is maintained.28

Proponents of the nonoperative management approach suggest that many high-grade injuries will heal without surgery, complications can frequently be managed with nonsurgical techniques (percutaneous drainage, stenting, angiographic embolization), and renal salvage rates are better overall when renal exploration is avoided. This school of thought would maintain that, with few exceptions, it is only hemodynamic instability that should prompt surgical intervention for the injured kidney, not injury stage or other predetermined imaging criteria.

In contrast, proponents of a more aggressive surgical approach would suggest that higher grades of renal injury carry an unacceptably high complication rate and that such complications, when they occur, have a high likelihood of resulting in otherwise avoidable morbidity or nephrectomy (Fig. 36-15). Proponents would suggest that early exploration and repair offer the advantage of early debridement of devitalized tissue, definitive hemostasis, repair of injuries to the collecting system, and early institution of appropriate drainage. As such, postinjury infection, urinoma, and hemorrhage risk are minimized. The descriptions of “absolute” and “relative” indications for renal exploration for trauma have been suggested to attempt to provide assistance in this decision-making process.4648

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FIGURE 36-15 Grade V parenchymal injury. (A) This image through the upper abdomen demonstrates the upper pole of the left kidney to be elevated by a perinephric hematoma. The upper pole is well perfused and intact. (B) A lower section reveals a large, left retroperitoneal hematoma; the right kidney is perfused and appears normal. This is an early arterial and parenchymal phase, as indicated by the degree of enhancement of the aorta and right renal cortex. (C) A more caudal image demonstrates a large, devascularized fragment of the left kidney; this represents the lower third of the kidney that has been avulsed from the perfused portion of the kidney. This injury required operative repair, which involved removal of the avulsed parenchymal fragment, suturing of the large intrarenal vascular branches that were avulsed, and reconstruction of the collecting system and the level of the junction of the lower infundibulum with the renal pelvis. While some reports suggest that some grade V injuries may be manageable nonoperatively, most clinicians consider this anatomy of injury a surgical indication. Difficulties in classifying some parenchymal injuries as grade IV versus grade V may contribute to this apparent reported variability of opinion and outcome.

For certain injuries, operative management is nearly universally accepted. These include blunt avulsion or penetrating lesions of the renovascular pedicle, AAST grade V parenchymal injuries, and ureteropelvic avulsion or complete avulsion of the fornices. While occasional case reports have suggested that grade V renal injuries can be managed nonoperatively, most studies demonstrate that 90–100% of such injuries require urgent nephrectomy.49 In reviewing the literature on nonoperative management of grade V renal injuries, the accuracy of classification is questionable, and some reports of successful management of grade V injuries probably are actually describing grade IV parenchymal lacerations. In general, attempts at nonoperative management of true grade V renal injuries are not advised and may expose the patient to substantial risk, although there remains some controversy in this area.50

Patients with significant ongoing bleeding from an injured kidney where angiographic control is not likely to correct the problem, is not available, or has failed also require prompt operative attention. For penetrating renal injuries in cases where laparotomy will occur regardless, especially when preoperative radiologic staging has not been performed or is incomplete, operative management is widely recommended.

When moderate or high-grade renal injuries are selected for nonoperative management, certain general principles apply. Such patients are at risk for continued bleeding or significant delayed bleeding, and it is important that they be observed in the surgical intensive care unit. Serial abdominal examinations are essential, as are serial laboratory studies including hemoglobin level and electrolyte status. Typed and cross-matched blood should be available for the first 24–48 hours. The patient’s hemoglobin should be maintained in such a range that a sudden drop from renewed bleeding would not be catastrophic. Particular attention should be paid to the size of the perirenal hematoma on initial imaging. Large hematomas suggest bleeding from larger intrarenal vessels and, presumably, indicate cases in which the risk of continued bleeding is greater. Elderly patients or patients with cardiovascular disease should be transfused more liberally, with a low threshold for intervention, as any sudden substantial blood loss may not be tolerated. When managing high-risk renal injuries nonoperatively, it is advisable to reimage such injuries at 48–96 hours to allow early diagnosis of complications such as enlargement of the perirenal hematoma, formation of a urinoma, or evolution of ischemic parenchyma. Early knowledge of such untoward events allows for treatment before the patient demonstrates complications such as sepsis, azotemia, or severe anemia.51

It is routine to impose a period of strict bed rest with nonoperative management of a major renal injury, although specific data to support this policy are lacking. Nevertheless, it seems reasonable to have the patient remain at bed rest for the first 24–72 hours or until significant gross hematuria resolves, and then reinstitute ambulation cautiously and in a monitored environment. If nonoperative management has been successful, patients should be instructed to avoid significant physical exertion until follow-up imaging reveals adequate healing.

Selecting between renal exploration and observation when the incompletely staged renal injury is encountered intraoperatively is difficult. Some authors recommend that the unstaged kidney be routinely explored, while others suggest a more selective approach. If no radiographic information is available, an intraoperative IVP may be selectively obtained to assist in this decision. A standard technique would involve the bolus injection of iodinated contrast (2 mL/kg body weight), and then obtaining a 10-minute excretion film. If significant anatomic distortion is observed, this is considered suggestive of major parenchymal disruption and/or injury to the collecting system, for which exploration may be of benefit. If the kidney appears grossly intact, observation would be selected, often with postoperative CT scanning for more precise imaging. Others would consider the size of the perirenal hematoma as an important parameter as well. In general, current trends in the urologic literature favor nonoperative management of most blunt renal injuries in the absence of staged grade V lesions, active bleeding noted intraoperatively, or hemodynamic instability.

Injuries to branch renal arteries from blunt trauma, resulting in segmental devascularization without laceration, can be managed nonoperatively with a low complication rate.

Penetrating injuries to the kidney are accompanied by injury to nonurologic organs in a large proportion of cases, and the majority of these patients will undergo laparotomy. These patients may or may not be imaged preoperatively. The issue of whether to explore the (suspected) renal injury in such cases is addressed in Section “Operative Management of Specific Genitourinary Injuries.” When the general trauma surgeon sees no clear operative indication and penetrating renal injury is possibly present, the urologist will have to decide on operative versus nonoperative management based on the clinical status of the patient and, preferably, on the findings of a contrast-enhanced CT scan. In general, patients with penetrating injuries to the kidney that involve the lateral and peripheral parenchyma, with small perirenal hematomas, minimal if any extravasation of contrast, and in which the pedicle and renal sinus structures are not at risk, may be safely managed nonoperatively (Fig. 36-16). Conversely, penetrating renal lesions that result in large perirenal hematomas, traverse the deep, medial renal parenchyma, renal sinus, or hilar region, or cause major urinary or vascular extravasation carry higher risks for nonoperative management (Fig. 36-17). The risk of delayed bleeding from such injuries is significant, and some authors have suggested prophylactic arteriography with embolization of violated arterial branches prior to nonoperative management. In addition, the risk of a missed associated visceral injury must be considered with nonoperative management of penetrating renal trauma. In one retrospective review of the nonoperative management of penetrating renal trauma, 55% of renal stab wounds and 24% of renal gunshot wounds were managed nonoperatively with a low complication rate.52

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FIGURE 36-16 Penetrating renal injury, successful nonoperative management. (A) Stab wound to left flank, just posterior to midaxillary line; patient is hemodynamically stable, with gross hematuria that rapidly clears. (B) Staging computed tomography scan demonstrating laceration to lateral left kidney. There is minimal perinephric hematoma, no urinary extravasation, and no devitalized parenchyma. Injury is lateral and laceration does not extend into hilar region or renal sinus structures. Posterior descending colon is in proximity to injury, but general surgeons are prepared to manage nonoperatively. Ideal candidate for nonoperative management of a penetrating renal injury.

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FIGURE 36-17 Penetrating renal injury, complicated. (A) Staging CT scan of abdomen following single stab wound to right posterior flank, in patient presenting with gross hematuria. Deep laceration of right kidney with moderate-sized perinephric hematoma. Injury extends into renal sinus region, although no contrast extravasation is noted. After initial attempt at nonoperative management, patient develops major secondary hemorrhage manifested by profuse gross hematuria, resulting in hypotension, and requiring transfusion of 4 U packed red blood cells. (B) Arteriogram reveals two areas of arteriocalyceal fistula, successfully managed with subselective embolization. (C) Delayed arteriogram image demonstrates wedge-shaped infarct defect due to embolization. Remainder of hospital course uneventful. Embolization is ideal means of managing this problem, as the only indication for intervention is hemorrhage.

While an uncommon injury, blunt or penetrating trauma to the adrenal gland deserves brief mention. If an adrenal hematoma is not expansile, it is managed nonoperatively as with parenchymal injuries to other solid organs. If the adrenal is explored due to the path of a stab or bullet wound, suturing to achieve hemostasis is the standard approach, while extensive destruction of the gland is treated with adrenalectomy. As each adrenal gland has several sources of arterial blood supply, devascularization from trauma is rare.

Image Ureter

Nonoperative management of ureteral trauma has limited applications. When a ureteral injury is recognized intraoperatively, surgical repair is favored (see later).32,53,54 Reviews of outcomes of ureteral injuries indicate that most types of ureteral trauma fare better with early operative repair, as compared with delayed repair or attempts at nonoperative management, with the exception of limited iatrogenic injuries from endoscopy. This is the case for stab and gunshot wounds, as well as avulsion injuries from blunt trauma (Fig. 36-18). Nonoperative management is performed in selected patients with missed ureteral injuries or other settings of delayed diagnosis or in patients in whom damage control strategies are being adopted. Traditional urologic teaching dictates that if ureteral trauma is recognized in the early days after injury, operative repair is performed. More significantly delayed recognition is managed with utilization of endoscopic or interventional radiologic techniques (stenting or percutaneous nephrostomy diversion) followed by delayed operative reconstruction as indicated. This approach has developed due to the long-standing recognition of problems such as inflammation, edema, friability, presence of a urinoma, and increased risks and complications of reconstructive efforts encountered when operative intervention is pursued greater than 3–5 days postinjury. Ureteral contusions recognized intraoperatively, due to either penetrating or blunt trauma, may be managed nonoperatively and simply observed; however, some reports suggest that the risk of late perforation and urinary extravasation may be reduced by intraoperative insertion of a ureteral stent.55

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FIGURE 36-18 Ureter: gunshot wound to ureter with missed injury, in a patient who had no hematuria on initial presentation. Patient developed abdominal fluid collection postlaparotomy; intravenous pyelogram demonstrated missed ureteral injury 5 days postoperatively. Injury initially managed with percutaneous nephrostomy and antegrade placement of universal stent. Long, densely fibrotic stricture of midureter developed, as shown here, ultimately requiring nephrectomy. A high index of suspicion is necessary to detect penetrating ureteral injuries at the time of initial laparotomy; outcomes are significantly improved with early recognition and prompt operative repair in such cases.

When nonoperative management is selected, retrograde ureteropyelography with attempted retrograde stent placement is often performed. Alternatively, percutaneous renal drainage may be the treatment of choice. The selection between these two approaches depends on the hemodynamic and metabolic stability of the patient, as well as specific anatomic and logistical factors. These include the appropriateness of performing a procedure under general anesthesia, the ability of the patient to undergo a procedure in a prone position (generally necessary for obtaining percutaneous renal access), the skill and availability of interventional radiology, and the expected ease of percutaneous access. The latter depends largely on the anatomy of and degree of distension of the collecting system and the presence of a perirenal hematoma. The finding of coagulopathy is often considered a relative contraindication to percutaneous renal drainage, as renal bleeding is always a risk of such procedures. Achievement of percutaneous access can be followed by antegrade ureteral stenting, if there is ureteral continuity and a guidewire can be placed across the injury into the bladder. Conversion of a nephrostomy tube to a percutaneous antegrade universal stent, which can be changed or manipulated and opened to external drainage or capped to allow internal drainage, may be attempted. Following an appropriate period, a pullback antegrade nephrostogram will determine if healing is complete and the patient is ready for stent removal with clamping of the nephrostomy tube.

When this type of management is utilized, a rate of ureteral strictures of up to 50% may be expected. A stricture may undergo an attempt at endourologic management, although delayed surgical reconstruction of the ureter is often necessary.

With blunt trauma, limited ureteral injuries with minimal extravasation may be treated nonoperatively with a retrograde stent. Retrograde pyelography is often necessary to document anatomy amenable to such management. For penetrating injuries, small-gauge shotgun pellet wounds may create minute ureteral perforations that can be managed nonoperatively as well. Such injuries may be noted at laparotomy or may be seen on a contrast-enhanced CT or intravenous or retrograde pyelography. Again, such cases represent the rare exception to the general principles favoring early operative exploration and repair when technically and medically feasible.

Image Bladder

Nonoperative management of extraperitoneal injury to the bladder has been the standard approach for over 10 years, largely as a result of the studies of Corriere and coworkers and others in which catheter drainage alone was usually successful.56,57 An 18–20 French or larger bladder catheter should be utilized to allow free drainage in the adult. The catheter is left indwelling for 10–14 days followed by a cystogram to confirm cessation of extravasation prior to removal. After this period, >85% of bladder injuries will show absence of extravasation. If extravasation persists, another 7–10 days of catheter drainage followed by repeat cystography is appropriate. Rarely, persistent extravasation will occur after a prolonged period of catheter drainage. In such cases, CT scanning and/or cystoscopy is indicated to be sure a foreign body such as a bony spicule from a pelvic fracture or some other anatomic cause is not resulting in failure of the laceration to heal properly. Indications for initial selection of operative management instead of catheter drainage alone include concomitant injury to the vagina or rectum, injury to the bladder neck in the female, avulsion of the bladder neck in any patient,58 and the need for pelvic exploration for other surgical indications. If retropubic access is required for internal fixation of a pelvic fracture, surgical repair of the bladder is desirable to prevent continued extravasation adjacent to orthopedic hardware. Open pelvic fractures may also require operative repair of the bladder. The presence of combined extraperitoneal and intraperitoneal rupture or combined extraperitoneal bladder rupture and posterior urethral injury, for which catheter realignment is planned, would be considered an appropriate setting to proceed with operative repair of the bladder as well. Finally, clot formation with troublesome occlusion of the drainage catheter may mandate operative repair.59

Intraperitoneal ruptures of the bladder are uniformly managed with operative repair. Most such injuries result in large, stellate tears in the dome of the bladder due to the sudden rise in pressure within a full bladder as from a blow to the lower abdomen or compression by a seatbelt. Rare exceptions to the routine application of operative repair for intraperitoneal bladder rupture include minimal intraperitoneal perforations. These usually occur during cystoscopic procedures, mainly when a resectoscope is being utilized for resection of a bladder tumor or during biopsies of lesions of the dome and anterior wall, or other minimal iatrogenic injuries. Several reports have appeared in recent years describing laparoscopic techniques of repair for iatrogenic injuries,60,61 particularly when occurring during a primary laparoscopic procedure. The application of techniques of laparoscopic repair to the management of intraperitoneal rupture of the bladder from blunt trauma and other forms of bladder injury is being explored at several centers.

For penetrating injury to the bladder, nonoperative management is occasionally applicable in carefully selected and fully evaluated patients with limited defects that are extraperitoneal.62 Such patients often require proctoscopy and/or sometimes arteriography. Selectively, peritoneal lavage or laparoscopy may play a role in such cases to ensure that the peritoneal surface of the pelvis is intact. In our experience, cystoscopy and upper tract imaging (IVP or retrograde pyelography) has been helpful in assuring that the magnitude of the defect in the bladder is minimal and is likely to heal with catheter drainage alone. The considerations for conversion to operative management and postinjury monitoring and imaging and catheter management are comparable to those utilized with blunt extraperitoneal injuries.

Image Urethra

The nature (blunt or penetrating), location of the injury (anterior vs. posterior urethra), completeness (partial vs. complete circumferential laceration), presence and seriousness of associated injuries, and the stability of the patient all impact the selection of management for urethral trauma.6365 When urethral trauma is suspected, RUG should be performed. If the RUG reveals minimal extravasation and flow of contrast past an anterior injury from blunt trauma into the proximal urethra and bladder, some authors have suggested that a single attempt at gentle passage of a bladder catheter should be performed. Other urologists believe that even minimal blind instrumentation of the injured urethra is ill-advised, preferring an endoscopically guided approach. In this author’s opinion, endoscopically guided instrumentation of the injured urethra is preferable to blind insertion of a catheter. The most conservative recommendation is to avoid any blind instrumentation of the injured urethra by the nonurologist. For incomplete anterior urethral injuries, urethral catheterization is reasonable therapy. Catheter-realignment techniques for posterior urethral trauma fall within the realm of the experienced urologist and constitute operative therapy and will be discussed later. Penetrating injuries to the anterior urethra are generally managed with operative exploration and repair.66Penetrating injuries to the posterior urethra may present complex challenges in management, may be complicated by adjacent rectal injury or other intrapelvic or visceral injury, and are also considered later.

Image Genital Injuries

While penile fractures and testicular ruptures are best managed with early recognition and operative exploration and repair, certain genital injuries due to blunt trauma may be managed nonoperatively.67 This would be the case when the injury is limited to the subcutaneous tissues, the tunica albuginea and urethra of the penis are intact, and the tunica albuginea of the testes is intact as well. For penile injuries, nonoperative management is appropriate for rupture of subcutaneous vessels resulting in limited ecchymoses or a hematoma. Scrotal trauma may be managed nonoperatively when the testis is intact and there is a limited hematocele that is not particularly uncomfortable for the patient. In most situations, however, significant genital trauma is best managed by operative exploration and repair. If physical findings are suspicious for significant injury to deep tissue or such injury cannot be ruled out by imaging studies, operative exploration is prudent. This is because the outcomes of nonoperative management of such injuries as penile fracture or testicular rupture are poor, as compared with the very high success rates of early operative repair of such injuries.68 As the relative morbidity of surgical exploration of the external genitalia is minimal and the morbidity of missed injuries or delayed recognition is significant, one should err in the direction of operative management for such injuries.45,69

A scrotal ultrasound demonstrating heterogeneity of the testicular parenchyma is suggestive of testicular rupture, even if clear loss of continuity of the investing tunica albuginea cannot specifically be identified.70 Certainly, if a clear defect in the continuity of the testicular tunic is noted on ultrasound, the diagnosis of testicular rupture should be suspected and operative repair undertaken. Patients with a significant hematocele (blood and/or clot within the tunica vaginalis compartment) with an intact testis may be observed, although they may often have a quicker recovery of activity and more rapid resolution of scrotal pain and swelling if this lesion is evacuated surgically. An intratesticular hematoma without testicular rupture is generally managed nonoperatively. At times, testicular ultrasound may demonstrate an abnormality in which a preexisting testicular lesion such as a germ cell neoplasm is suspected. Such may be the case when relatively minor trauma causes a significant intratesticular bleed or testicular rupture. When preexisting testicular pathology is suspected and nonoperative management is selected for the traumatic lesion, it is critical that the testis be reevaluated until the suspicious abnormality resolves or its continuing presence mandates further imaging and intervention.

For genital injuries involving significant loss of soft tissue or skin, nonoperative management may be appropriate as an initial approach, especially when more immediately life-threatening injuries demand priority. Wounds should be cleansed and a conservative approach should be adopted when determining whether to perform debridement of genital skin or soft tissues of marginal or questionable viability. Secondary operative management and delayed reconstruction with skin grafting or other tissue transfer techniques is often necessary when wounds are initially managed in this manner.71

OPERATIVE MANAGEMENT OF SPECIFIC GENITOURINARY INJURIES

Image Kidney

Renal exploration for trauma begins with prioritization of the injuries and determining that the initial operation is in fact the appropriate time to embark on the renal exploration (see Section “Damage Control Principles in Genitourinary Trauma”). When contemplating exploration of an injured kidney in the absence of preoperative imaging, some assessment of the presence and normalcy of the contralateral kidney should be undertaken. Palpating the contralateral renal fossa for a grossly normal kidney is certainly appropriate and is often the only assessment necessary. In selected cases, an intraoperative IVP may provide more precise information. This can be performed by administering 1–2 mL/kg of iodinated contrast intravenously and then obtaining a 10-minute excretion film. This can occur while other general surgical tasks are being accomplished to avoid wasting time. While an intraoperative IVP provides some additional reassurance that a functional contralateral kidney is present when exploring an injured kidney, in our center we generally proceed with exploration of the injured kidney based on contralateral renal palpation alone.

If it is jointly determined by the urologist and the general surgeon that renal exploration should occur, exploration is carried out through an anterior vertical incision in Gerota’s fascia. There has been some controversy regarding the importance of first obtaining vascular control of the renal pedicle prior to renal exploration as previously described.72,73 Some proponents claim a markedly reduced nephrectomy rate if the renal vessels are first dissected and controlled with vessel loops. Others claim that this maneuver is unnecessary to successful renal exploration and repair. This controversy is probably overstated, as even those who do not believe that individual dissection of the renal vessels is essential prior to renal mobilization generally use some other approach to control the pedicle or limit renal bleeding during examination and repair of the kidney. The bulk of the literature would suggest that the rate of otherwise unnecessary nephrectomies is minimized by having exposure and control of the renal pedicle prior to renal exploration. This can be achieved by the traditional maneuver of incising the posterior peritoneum lateral to the aorta and individually dissecting and looping the renal vessels on the side of injury (Fig. 36-19). This can also be achieved by reflecting the colon medially first, and then clamping the pedicle if significant bleeding is encountered on opening the Gerota’s fascial envelope (Fig. 36-20). Alternatively, the pedicle or the renal parenchyma can be compressed digitally (most applicable to polar injuries) without having individual control over the renal vessels. Certainly if there is an injury to the pedicle, suggested by a large or expanding medial hematoma in the vicinity of the great vessels, there is broad agreement that central vascular control should be the initial maneuver.

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FIGURE 36-19 Surgical management of renal trauma: vascular control. Diagram demonstrating early vascular control prior to renal exploration. (A) The posterior peritoneum is opened over the aorta medial to the inferior mesenteric vein. (B) The renal vessels are individually dissected and surrounded with vessel loops. (C) The colon is reflected medially exposing the perinephric hematoma. Some clinicians believe preliminary control of the renal vessels is not necessary when performing renal exploration for trauma, although best renal salvage rates are reported when vascular access or control is obtained.

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FIGURE 36-20 (A) Alternate means of obtaining vascular pedicle access prior to renal exploration. Colon is reflected medially initially. Blunt dissection lateral to vena cava allows creation of space anterior to psoas muscle for placement of pedicle clamp if necessary on renal exposure. (B) Comparable technique on the left side, creating space for pedicle clamp lateral to aorta. This approach has been used successfully in the author’s center.

Following pedicle control or access, the colon and mesocolon on the side of injury are dissected medially following incision of the peritoneal reflection. When the anterior surface of Gerota’s fascia is fully exposed, a generous, vertical, anterior incision is made through the fascia, and the kidney is fully mobilized. As indicated earlier in Section “Anatomy,” it is important to dissect in an extracapsular plane and avoid inadvertently dissecting the renal capsule away from the underlying cortex. Accomplishing this is facilitated by beginning the dissection in an area of intact parenchyma rather than directly within the laceration. Completely mobilizing the kidney is very helpful, as it allows the kidney to be lifted anteriorly into the wound for complete inspection. If significant bleeding results during this maneuver, a noncrushing vascular clamp is applied to the renal artery, renal vein, or entire renal pedicle. An initial decision must be made regarding renal salvageability and the magnitude of the reconstructive effort that would be required to repair the injury. This is based largely on the amount of devitalized parenchyma, the degree of injury to the central vasculature and central collecting system, and the condition of the patient. If the kidney is felt to be reconstructible in an unstable patient, any significant intrarenal vascular injury can be rapidly sutured and the kidney can be packed off with laparotomy pads as other surgical injuries are treated (see Chapter 41). After repair of other injuries, or at the time of a secondary surgical procedure, formal exploration and reconstruction of the kidney is performed.

If, based on the anatomy of the injury, the kidney is not considered reconstructible, a nephrectomy is performed. It is preferable to separately ligate the renal artery and vein to avoid the potential for arteriovenous fistula. A rapid search is made for accessory or polar vessels, which must be ligated also. While urologists frequently suture or simply ligate the renal artery and a long stump of vein, vascular surgeons and some urologists prefer to oversew the short right renal vein with a continuous 3-0 or 4-0 Prolene suture. For trauma nephrectomies, the ureter and adjoining vessels are ligated near the kidney, while the gonadal vein is ligated and divided when necessary, with no need for concern for adverse impact on the gonadal structures.

If renal reconstruction is planned, several steps are generally followed (Fig. 36-21). Following evacuation of the hematoma, the kidney is carefully examined to identify lacerated vessels, the open collecting system, and devitalized parenchyma. Large areas of lacerated, devitalized parenchyma are excised sharply, with smaller vessels controlled with an absorbable 3-0 or 4-0 suture. In general, an absorbable suture is utilized for intrarenal suturing, as a permanent suture may create a nidus for stone formation if in contact with the collecting system. If adequate closure of the collecting system is achieved, there is no need for stenting or a nephrostomy. If repair of the collecting system is tenuous or incomplete, placement of an internal stent (complemented by a bladder catheter) or a nephrostomy tube may decrease the risk of postoperative urinary extravasation and the formation of a urinoma.

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FIGURE 36-21 (A and B) Wedge resection of injured parenchyma. (C) Suturing of open collecting system and significant vessels with absorbable suture. (D) Capsule, if present, may be closed, or reconstructed using peritoneal patch, with absorbable gelatin sponge or local fat pedicle to aid in hemostasis.

Partial nephrectomy for polar lesions is performed by a “guillotine” technique, with the transected vessels and collecting system closed as noted earlier (Figs. 36-22 and 36-23). Topical hemostatic agents may be placed within a parenchymal defect to aid in hemostasis, with the capsule closed over the defect and the hemostatic material. If the capsule can be closed with mattress sutures or absorbable bolsters following debridement or partial nephrectomy, parenchymal hemostasis is aided considerably. If capsular closure is not feasible either due to the shape and location of the parenchymal defect or due to loss of the capsule from the injury or dissection, utilizing absorbable materials or native tissue as a patch may be helpful if hemostasis is still problematic. The argon beam coagulator has also been utilized successfully in the kidney to achieve hemostasis in the parenchyma, after suturing larger vessels and closing the collecting system. Topical hemostatic agents and tissue adhesives may be used on the kidney, collecting system, ureter, and other urologic repairs to aid in hemostasis and minimize the risk of postoperative urinary extravasation.74 Some data exist to suggest that the application of fibrin sealant over a urinary tract suture line may decrease the likelihood of postoperative urinary leakage.75 At times, wrapping the decapsulated kidney in absorbable mesh material has been utilized to provide mild temporary parenchymal compression for continued venous bleeding from lacerated parenchyma (Fig. 36-24).

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FIGURE 36-22 (A and B) Partial nephrectomy for major injury to upper pole. (C) Repair of collecting system and suturing of bleeding vascular branches. (D) Mattress sutures of 2-0 chromic gut to reconstruct parenchyma and aid in hemostasis.

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FIGURE 36-23 Surgical management of renal trauma. (A) Partial nephrectomy for lower pole laceration due to gunshot wound. Excised fragment of devascularized, lower pole parenchyma, debrided. Bullet removed, found immediately posterior to kidney. (B) Appearance of lower pole following suture repair of vessels and repair of collecting system. Capsule has been reflected back for completion of partial nephrectomy and will be used for coverage of defect. (C) Defect covered with absorbable gelatin sponge soaked in thrombin. Note vessel loops surrounding renal vessels. (D) Defect covered with adjacent capsule and peritoneal patch, to aid in hemostasis. (E) Duodenal injury, repaired, immediately anterior to the renal injury. It is desirable to separate such injuries with viable tissue interposition, when possible, to minimize the risk of postoperative leak from either source affecting the other repair. (F) Gerota’s fascia closed over the kidney to separate the duodenal and renal injuries. Omental pedicle flaps are also very useful for this purpose. The renal repair was drained with an extraperitonealized closed-suction drain.

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FIGURE 36-24 Surgical management of renal trauma: renal parenchymal injury due to blunt trauma. (A) Large, deep laceration through posterior parenchyma, left kidney. Bleeding sites are sutured, collecting system closed with absorbable suture. Venous bleeding continues from lacerated cortex. (B) Due to absence of renal capsule (dissected away from parenchyma by hematoma), absorbable surgical mesh is used to wrap renal parenchyma providing gentle compression to assist in achieving hemostasis.

Injuries to adjacent organs such as the liver, pancreas, duodenum, and colon generally do not change the indications for renal salvage versus nephrectomy,76,77 as good results have been described for renal repairs in the setting of injuries to these adjacent organs. It is desirable, however, to separate the renal injury from the adjacent visceral injury using available viable tissue. This can be accomplished by replacing the kidney within Gerota’s fascia and closing the fascial layer over the kidney or by utilizing omentum in the form of a pedicle flap. Drains for renal injury are utilized when injury complex or incompletely repaired injuries to the collecting system are present, or there is concern for the need to evacuate blood postoperatively. Closed-suction drains are used as there is a lower risk of contributing to postoperative infection. In the setting of injury to an adjacent organ, the organ sites should be drained separately.

Certain injuries are more common in the pediatric population and deserve specific mention. Avulsions of the fornices, ureteropelvic junction, and renal pedicle are more commonly seen in the pediatric population than they are in the adult.26 Complete forniceal avulsion injuries are managed with nephrectomy as repair is nearly impossible. Avulsions of the ureteropelvic junction are amenable to repair through a direct anastomosis. Lacerations of the renal pelvis should also alert the trauma surgeon to the possibility of a preexisting obstruction of the ureteropelvic junction. Repair of the obstructing lesion may need to be performed with closure of the pelvis, or nephrectomy may be preferable if the kidney appears to have minimal parenchyma due to long-standing obstruction.

Renovascular injury from blunt or penetrating trauma presents certain challenges (see Chapter 37). As noted earlier, selected patients are taken to laparotomy for revascularization surgery based solely on a CT scan demonstrating the classic findings of renal nonperfusion following deceleration trauma. If exploration is undertaken based on the CT findings or if arteriographic imaging has been performed, the approach is similar. The artery is dissected from its origin at the aorta toward the kidney and the arterial pulse is palpated or assessed with a Doppler instrument. The artery is clamped near the aorta and opened at the circular ring of hematoma, resected to the point of normal anatomy, and a direct end-to-end anastomosis performed. When necessary, an autogenous vein graft or prosthetic graft is interposed. As in the pediatric population (in which the injury is more common), avulsion injuries involving the renovascular pedicle require urgent surgical intervention. Most such patients are managed with nephrectomy, although isolated vascular repairs have been described depending on the level of the avulsion. Avulsion of multiple branches from within the renal sinus is virtually impossible to repair in the trauma setting and generally requires nephrectomy as well. While current data suggest that the likelihood of achieving a favorable outcome with renal revascularization following renal injury is low,78 patient selection is critical. In the appropriate clinical setting (brief warm ischemia time and a patient in suitable condition for surgery), the effort may be worthwhile in carefully selected patients. A collaborative approach involving the vascular surgeon and the urologist is highly applicable to cases in which renovascular reconstruction is planned. In selected cases in which an intimal disruption of the renal artery is documented arteriographically but perfusion is maintained, radiologic placement of a vascular stent may be applicable. Many limited penetrating injuries to the renal vein can be repaired, while arterial injuries have a high rate of nephrectomy. Injuries to branch vessels in a parenchymal laceration are ligated. When diagnosed on imaging studies in stable patients with intact parenchyma, nonoperative management is appropriate.

Bilateral renal injuries are rare and present special problems.79 Assuming neither kidney is bleeding briskly, the kidney that seems to be less seriously injured (based on hematoma size and location, apparent orientation and location of entrance and exit wounds, etc.) is assessed to be sure that renal salvage is feasible. One kidney can also be packed off temporarily after obtaining gross hemostasis while the opposite kidney is assessed in an effort to avoid nephrectomy in these cases whenever possible.

Although rarely indicated, ex vivo renal reconstructive surgery may be utilized in the trauma setting. This would be the case when a solitary (functionally or anatomically) kidney is injured, and a complex reconstruction is needed for salvage.

Image Ureter

The approach to ureteral repair depends largely on the level of the injury, the amount of ureteral loss, if any, and the condition of the local tissues. A ureteral laceration along with extensive destruction of the kidney from blunt or penetrating trauma is generally managed with nephrectomy. If the kidney is uninjured or the renal injury is limited and can be observed or repaired, ureteral repair is best performed at the time of recognition.80,81

Injuries to the ureter from blunt trauma require a high index of suspicion for diagnosis. Hematuria may be absent in such cases, and a delayed presentation is not uncommon. As noted earlier, the spiral CT scanners complete the initial renal imaging survey so rapidly that, unless a delayed excretory phase is requested, the study may be completed before the contrast has opacified the collecting system or injured ureter.

Blunt avulsion of the proximal ureter or ureteropelvic junction is best managed with limited debridement to viable tissue and a spatulated end-to-end anastomosis using fine absorbable suture (3-0, 4-0, or 5-0). In general, ureteral repairs performed after trauma are most often stented. This can be performed with an internal double-J-type stent or an externalized single-J stent. The single-J stent is usually exteriorized through a small stab incision in the anterior bladder wall and secured with a purse-string suture. Some surgeons also secure the stent to the bladder mucosa just outside the ureteral orifice with a fine absorbable suture (4-0 or 5-0). For tenuous repairs of the proximal ureter, diversion using a nephrostomy tube may be considered, but it is generally unnecessary.

A blunt injury to the midureter is uncommon, but when it is diagnosed, it is managed with a primary anastomosis. In the distal ureter (below the internal iliac artery), ureteral reimplantation into the bladder is preferred.

Injuries to the ureter from penetrating trauma also require a high index of suspicion for diagnosis. The presence of urine in the operative field may be difficult to appreciate, and the ureters, when at risk, must be thoroughly assessed by intraoperative inspection. The proximal and midureters down to the internal iliac arteries are easy to visualize and examine. For very distal injuries, a vertical cystotomy with observation of efflux from the ureteral orifices and intraoperative retrograde pyelography may be a less morbid means of assessing the area of concern, rather than embarking on a difficult dissection of the ureter all the way to the bladder in the setting of a pelvic hematoma. Alternatively, intraoperative flexible cystoscopy with retrograde pyelography may be performed, avoiding the cystotomy. For proximal and midureteral injuries, limited debridement of damaged tissue and a tension-free, spatulated end-to-end anastomosis is the procedure of choice (Fig. 36-25). For very distal injuries (generally below the internal iliac artery), reimplantation into the bladder is preferred as noted earlier as the blood supply to the distal ureteral stump may be compromised. A direct anastomosis to the bladder avoids the potential ischemic complications of a very distal ureter-to-ureter anastomosis. Stenting of such repairs is routine as described previously.

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FIGURE 36-25 Techniques of ureteral reconstruction. Debridement and primary anastomosis for ureteral transection from gunshot wound. (A and B) Mobilization of ureter superficial to adventitial plane. (C) Limited debridement of lacerated ureter to viable tissue with spatulation for repair. (D and E) End-to-end anastomosis with fine absorbable suture, over stent (not shown).

For injuries to the lower third of the ureter, it is not always possible to perform a direct anastomosis to the bladder without tension. In such cases, the bladder can be brought cephalad and lateral toward the injured side to achieve a tension-free anastomosis with the ureter by several techniques. The most commonly employed is the “psoas hitch” (Fig. 36-26). The bladder is opened anteriorly, lateral peritoneal attachments are divided as needed, and then the bladder body is displaced toward the side of the injury and sutured to the psoas muscle with 2-0 absorbable suture, taking care not to injure or entrap any major nerves. The ureter can then be reimplanted into the bladder using a tunneled antirefluxing anastomosis, or the tunnel can be omitted if length is still a problem. It is important to ensure that no obstruction or acute angulation exists at the vesical hiatus where the ureter enters. If a psoas hitch cannot achieve a tension-free connection to the ureter, a bladder flap (Boari flap) can be created. This procedure has a higher complication rate than a psoas hitch and is performed only if the psoas hitch does not accomplish the required objective. The bladder flap may be performed in conjunction with the psoas hitch to maintain the cephalad extension of the bladder wall posterior to the flap. Again, a nonrefluxing tunneled or a refluxing repair can then be performed.

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FIGURE 36-26 (A) Ureteral reimplantation with psoas hitch for lower ureteral injury: the bladder is opened either transversely or vertically and obliquely toward the side of injury, and then hitched to the ipsilateral psoas muscle with 2-0 or 3-0 Vicryl suture. A tunneled, antirefluxing anastomosis of the ureter to the posterior wall of the bladder is performed, being certain that an adequate-width tunnel is created to prevent obstruction. If the available ureteral length is short, antirefluxing tunneling can be eliminated. Either an internal double-J-type stent or an externalized single-J stent can be used (not shown). (B) Psoas hitch ureteral reimplantation for penetrating injury to lower ureter, performed acutely during initial laparotomy in a hemodynamically stable patient. The bladder body can be seen sutured to the left psoas muscle, with the ureter entering cephalad. A single-J ureteral stent and suprapubic cystostomy exit from the bladder in the lower part of the photograph.

More complex techniques of ureteral reconstruction include transureteroureterostomy (TUU), ileal-ureteral replacement, and renal autotransplantation (Figs. 36-27 and 36-28). TUU is relevant when anastomosis to the bladder is not feasible due to inadequate length of the ureter or condition of the bladder, or when it is desirable to move the repair away from the ipsilateral hemipelvis due to local conditions of infection, prior pelvic radiation, etc. Ureteral replacement with the ileum is seldom performed in the acute trauma setting as it is preferable to have a fully prepped bowel when performing this procedure. Renal autotransplantation may be appropriate in the acute trauma setting if appropriate vascular surgical expertise is available and less complex options for ureteral replacement are not feasible. The proximal ureter can be anastomosed directly into the bladder, in the case of loss of the majority of the lower ureter, or an anastomosis can be performed to the lower ureter if it is clearly viable and not excessively distal.

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FIGURE 36-27 (A–C) Transureteroureterostomy for reconstruction following extensive mid and lower ureteral injury. Prior bladder surgery or pelvic inflammatory or neoplastic disease, among other factors, may make psoas hitch or bladder flap repair undesirable. The injured ureter is mobilized and transposed to the contralateral side underneath the mesentery, and then anastomosed with an end-to-side technique to the recipient ureter.

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FIGURE 36-28 Renal autotransplantation for reconstruction following extensive loss of midureter, making direct union of upper ureter to bladder impossible. Alternative to ileal-ureteral replacement of most of the ureter. Nephrectomy must be tailored to include as much of the renal vessels as possible to aid in anastomosis to iliac vessels (in general, vein generally transected flush with vena cava on right, with artery transected more proximally, behind vena cava, than shown here). Anastomosis of proximal ureter to viable lower ureter.

When ureteral repairs are performed in direct apposition to adjacent vascular or visceral repairs, separation of the repairs by an omental pedicle or other viable tissue is desirable to prevent a fistula or contact with urine at the site of the adjacent organ injury. External drainage of ureteral injuries, in addition to stenting or diversion, may be desirable, particularly if the repair is tenuous or the vascularity of the repaired tissues is questionable. Some urologists prefer Penrose drains for this purpose, to avoid having a closed-suction drain aspirating directly on a ureteral suture line. The author uses closed-suction drains, suturing them (with 4-0 chromic gut) to the psoas muscle or other adjacent soft tissue to prevent the drain from migrating directly onto the ureteral repair. In the postoperative period, antibiotic administration may be desirable, especially if urinary extravasation persists.

As noted later, ureteral injuries are also highly amenable to damage control strategies when the patient is not in suitable condition for repair at the time of the initial laparotomy. An external stent placed through the transected proximal ureteral stump allows maintenance of control of the urinary output while the patient is undergoing resuscitation in preparation for definitive delayed reconstruction.

Image Bladder

Surgical repair of the bladder is performed for many iatrogenic injuries, for nearly all blunt intraperitoneal injuries, and for selected cases of blunt extraperitoneal rupture. Penetrating injuries to the bladder are also usually managed with operative repair.

Intraperitoneal ruptures of the bladder are approached through a midline abdominal incision. The large laceration is nearly always in the dome of the bladder as previously described (Fig. 36-29). The interior of the bladder is palpated and inspected through the laceration to verify that no other injuries are present and that there is clear efflux from both ureteral orifices. The laceration may be extended into an anterior midline cystotomy if necessary for further assessment, but this is not usually necessary. The edges of the bladder laceration may require minimal debridement to remove devascularized tags of detrusor muscle or mucosa. The laceration is then closed using two layers of heavy absorbable suture. An adequate bore bladder catheter is used to allow free drainage of initially bloody efflux that clears in the first few days. The length of time of catheterization should consider the period needed for urinary efflux to clear and the ability of the patient to be ambulatory and void comfortably, but is usually 5–10 days. It is prudent to perform a cystogram prior to removal of the catheter following any operative repair, and it is mandatory with nonoperative management. As a well-sutured repair carries an extremely low postoperative risk of extravasation, some practitioners do remove the catheter without prior contrast imaging with excellent success. Suprapubic cystostomy catheters are not generally needed after repairs of intraperitoneal ruptures. They should be inserted only when there will be the need for long-term bladder drainage, as in the patient with a significant injury to the brain, trauma to the pelvis or a lower extremity, or other factors that would be expected to substantially delay a return to ambulation.

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FIGURE 36-29 Operative appearance of intraperitoneal bladder injury from blunt trauma. (A) The anterior bladder wall is retracted at the top of the photograph, with the typical large, stellate defect noted in the bladder dome. (B) Appearance of the bladder dome after closure in two layers of 2-0 chromic gut.

For the selected cases in which extraperitoneal rupture of the bladder is managed with operative repair, there are several important differences when compared with intraperitoneal repairs. When operating on the injured bladder during a laparotomy following a pelvic fracture, an effort should be made to avoid entering the retropubic hematoma. This avoids potentially serious hemorrhage from a site that is often tamponaded. If repair of the bladder is necessary in this setting (see Section “Nonoperative Management of Genitourinary Injuries”), one should enter the bladder through an anterior cystotomy incision cephalad to the pelvic hematoma. The laceration, which is usually located in the lower anterior or anterolateral bladder, can be sutured transvesically by introducing Deaver or malleable retractors into the bladder and retracting them laterally. Often, only a single-layer, full-thickness closure is possible in this setting. It is useful to communicate with the orthopedic surgeons when operating on extraperitoneal bladder ruptures in the setting of a pelvic fracture to allow for coordinated care.

A penetrating injury to the bladder is most often managed operatively, although occasional patients as previously described may be candidates for nonoperative management.62 If a patient is undergoing laparotomy and has gross hematuria following penetrating pelvic trauma, the peritoneal surface of the bladder is examined first. The retropubic space is then entered and an anterior, midline cystotomy is created. This may be easier to accomplish if the bladder is partly filled with irrigant. For laparotomies during which bladder surgery is likely, including the genitalia in the sterile field facilitates whatever manipulation may be necessary without abdominal contamination. Following cystotomy, the interior of the bladder is thoroughly examined, as are the ureteral orifices and the bladder neck. The urinary efflux from both orifices should be observed; if it is bloody or absent, further investigation for trauma to the ureters or upper tract is indicated. Penetrating injuries to the bladder are closed with two layers of absorbable suture as described earlier.

In some patients, an iatrogenic or penetrating injury to the bladder may result in loss of a large portion of the detrusor of the bladder body. Closure over a bladder catheter is still recommended, as the bladder may expand to an acceptable volume with time. If minimal bladder capacity persists following a reasonable period of healing, augmentation cystoplasty can be performed electively.

As for renal and ureteral injuries, injuries to the bladder in the unstable trauma patient are amenable to damage control strategies. These include externalized stenting of the ureters with pelvic packing and delayed repair of complex lacerations.

Certain associated injuries impact on the management of bladder trauma. Contiguous injury to the vagina or rectum is such an example, requiring close collaboration between the clinical services involved in caring for these injuries. When such injuries are suspected, it is helpful to have the patient in a modified dorsal lithotomy position so simultaneous access to the perineum and abdomen can be obtained. During surgical repair, the bladder should be separated from the rectum or vagina by placing an interposition flap of viable tissue if the loss of tissue is significant and the injuries directly overlie each other. This effort at separation of the pelvic organs can be difficult in the trauma setting and, if the injuries do not directly overlie each other and tissue loss is minimal, simple transvesical closure is generally adequate. In this setting, longer indwelling catheter times, perioperative antibiotics, and radiographic imaging prior to removal of the catheter are recommended. Open pelvic fractures are among the most devastating injuries in orthopedic trauma, and injury to the lower urinary tract may complicate such injuries. A close interaction between the urologist, orthopedist, trauma surgeon, and interventional radiologist is necessary for management of such patients. Chronic disability is common following such injuries.82

Avulsion injuries of the bladder neck, more common in the pediatric population, require operative repair (Fig. 36-30).58 Repair for these complex injuries may be best delayed until 24–72 hours postinjury to support a damage control strategy and to minimize the risk of excessive hemorrhage from an associated pelvic fracture.

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FIGURE 36-30 Bladder neck avulsion injury in an adult female with pelvic fracture. Operative appearance during surgical repair. An anterior midline cystotomy had been performed (to right in photo), with the tip of a Foley catheter protruding from the avulsed bladder neck for demonstration purposes. Anastomosis to urethral stump at level of pelvic floor performed over Foley catheter. The patient was initially managed with a percutaneous suprapubic cystostomy. This repair was performed 36 hours following injury, when the patient was hemodynamically stable and risk of excessive bleeding from the pelvic fracture would be lower.

Image Urethra

Operative management for urethral trauma includes the broad topic of elective urethral reconstruction following traumatic injuries and surgical repair of urethral strictures. There are excellent reviews available on this latter topic.83,84This discussion will focus on immediate and subacute surgical intervention for urethral trauma. Clinical guidelines have recently been reported for such injuries.85

Anterior urethral injuries that are incomplete may be managed with placement of a transurethral catheter or with suprapubic diversion. As noted above, the author favors using endoscopic guidance for any attempt to catheterize the traumatized urethra. If a blind attempt at catheterization is performed and any resistance is encountered, an endoscopically guided procedure should follow. Complete ruptures of the anterior urethra from blunt trauma are best managed with suprapubic diversion for ≥3 months, followed by elective end-to-end urethroplasty when the perineal hematoma and induration have fully resolved. Acute attempts at excision and repair are not recommended as it is unclear how much urethra to resect due to the crush injury and difficult to be sure that one is approximating viable, healthy tissue at the anastomosis.

Penetrating injuries to the anterior urethra may be managed with local exploration and repair or with suprapubic diversion. With stab wounds or gunshot wounds from low-velocity missiles, it is usually a simple matter to perform limited debridement and repair with a spatulated anastomotic technique. If the patient is not an appropriate candidate for immediate repair due to more pressing serious injuries, etc., suprapubic diversion or endoscopically guided insertion of a transurethral catheter placement is performed. Extensive loss of the urethra from penetrating trauma or industrial trauma may require a staged repair.

The management of disruption or distraction injuries of the posterior urethra remains controversial. In recent years, there has been increasing interest in early catheter realignment for such injuries. Techniques utilized have included endoscopic guidance, open surgical approaches, and (historically) the use of interlocking magnetic sounds (Fig. 36-31).8689 A potential advantage of endoscopic realignment is the possibility that the injury will heal free of intractable stricture. This would obviate the need for late urethroplasty, shorten the period of urinary intubation, and may improve the anatomic result as compared with the nonintubated state by reducing malalignment. The potential disadvantages of this approach are the risk of infecting the retropubic hematoma by the presence of the indwelling catheter with an adverse impact on late continence and sexual function and the high likelihood that a stricture will form anyway. When selected, catheter realignment should be performed by an experienced team in the operating room with endoscopic and fluoroscopic capability. Results are better for incomplete disruptions than they are for complete disruptions. Most patients managed in this manner do develop a stricture requiring endoscopic intervention, often involving multiple procedures. Overall, patients managed with catheter realignment may avoid a subsequent urethroplasty about 50% of the time.

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FIGURE 36-31 (A) Manipulating flexible cystoscope from above and rigid cystoscope sheath from below (beak placed at point of disruption at bulbomembranous junction), a guidewire is advanced across defect and continuity is achieved. A Foley catheter with end-hole punched is passed over the guidewire and positioned with balloon in bladder. Working sheath is removed after replacement of large-bore suprapubic catheter. This is one of a variety of techniques described for achieving catheter realignment using minimally invasive approaches. Primary urethral realignment for posterior urethral disruption. (Aand B) Access to bladder, previously obtained via percutaneous cystostomy, is utilized for realignment. Retrograde flexible cystoscopy failed to demonstrate continuity; therefore, suprapubic tract was dilated and working sheath was placed into bladder using both direct vision and fluoroscopic guidance.

The traditional approach to a posterior urethral distraction injury is diversion with a suprapubic cystostomy, followed by a period of observation of 3–6 months while the pelvic hematoma resolves and the anatomy stabilizes. Repeat antegrade and retrograde urethrograms are then performed, and definitive reconstructive surgery is planned. The ultimate success rate of this approach is over 90%; however, the need for a long-term indwelling suprapubic tube while awaiting surgery may be frustrating for the patient. Nevertheless, newer techniques such as catheter realignment must be compared with the excellent outcomes of patients managed in this traditional manner.90,91

Image Penis, Testis, and Scrotum

Penile trauma is nearly always managed through operative exploration and repair.92 For blunt penile fractures, the penis is explored through either a ventral midline penoscrotal incision or a circumcising subcoronal incision. The defect in the tunica albuginea is exposed and closed with absorbable suture (Fig. 36-32). The outcomes following early operative repair of penile fractures are far superior to those resulting from nonoperative management. Deformity, painful erection, pseudoaneurysm, and loss of erectile function are common in nonoperative management of such injuries (Fig. 36-33).68

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FIGURE 36-32 Penile fracture. Appearance of penis during surgical exploration for penile fracture sustained during sexual intercourse. Patient reported classic findings of pain, swelling, and detumescence following sudden marked bending of erect penis. Note marked swelling of distal phallus with subcutaneous hematoma. Penis is explored through a ventral, midline, penoscrotal incision. Dissection to area of palpable irregularity along penile shaft reveals transverse laceration of tunical albuginea of corpus cavernosum. A penile tourniquet, utilizing a Penrose drain, is in place to reduce bleeding during repair. The hooks are part of a ring-retractor system commonly used in genital surgery. The tunica albuginea defect is closed with running 3-0 Vicryl suture. Early exploration and repair for penile fracture injuries produces the best results. Circumcising, subglanular incision is preferred by some surgeons for this type of exploration and repair.

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FIGURE 36-33 Delayed presentation following penile fracture. (A) Note marked angulation to left with mass effect on right lateral side of penile shaft following untreated rupture. Patient presents 6 weeks postinjury; the subcutaneous hematoma has resolved, while the defect in the corpus cavernosum remains, resulting in angulation and pain with erection. (B) Appearance of penis at surgical exploration through circumcising incision. Note large encapsulated hematoma under Buck’s fascia, which, on incision, still communicates with cavernosal space. Defect repaired with correction of deformity.

Penetrating penile injuries, similarly, should be managed with operative exploration and repair (Figs. 36-34 and 36-35).93 As combined cavernosal and urethral injury occurs in roughly 10% of penile fractures, a preoperative urethrogram or flexible cystoscopy is useful in planning the repair.

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FIGURE 36-34 Gunshot wound to penis with entrance at dorsal penile base. (A) Extensive injury to skin and subcutaneous tissues and laceration of tunica albuginea of corpus cavernosum. Penile tourniquet in place to allow injury assessment while minimizing bleeding. (B) Tunica albuginea has been conservatively debrided and closed with running Vicryl suture. (C) Appearance of penis following reconstruction of glans and skin tube. Subsequent scar revision was necessary for necrosis of skin edges (not shown). Preservation of soft tissues and conservative debridement demonstrated.

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FIGURE 36-35 Gunshot wound to mons pubis region, cephalad and to left of penile base. (A) No palpable abnormality of penis is recognized. Small left scrotal hematoma present. (B) Surgical exploration of wound via oblique scrotal neck incision extends toward groin. Bleeding sites in left spermatic cord were controlled (not shown), followed by evacuation of hematoma resulting in significant bleeding. Dissection revealed complete transection of left corpus cavernosum at penile base, which was repaired. Case demonstrates importance of surgical exploration of penetrating injuries in proximity to male genitalia.

In cases of penetrating penile injury, a similar surgical approach is utilized, with conservative debridement, repair of cavernosal and urethral injury, and microsurgical repair of dorsal neurovascular structures when possible. For limited injuries, direct wound exploration may be preferable approach. The possibility of adjacent nonurologic injury (thigh, femoral vessels, pelvic organs) must always be considered in cases of penetrating genital injury.

Penile strangulation injuries due to constricting bands or other devices are managed with removal of the constricting object in as atraumatic a manner as possible. Distal penile skin, glans, cavernosal, or urethral necrosis can occasionally occur in such cases. A conservative approach to debridement of tissues of questionable viability and diversion with a suprapubic cystostomy tube if the urethra is compromised are principles of management.

Patients with traumatic amputation of the penis require specialized management (Fig. 36-36). Often, patients who suffer traumatic amputation through self-mutilation are psychotic and/or involved in substance abuse and require psychiatric as well as urologic intervention.94 The severed organ should be cleansed and kept in cold saline-soaked gauze in a sealed bag, which is then placed in ice. Replantation surgery is well described.95 In sequence, anastomosis of the corpora cavernosa, urethra, dorsal blood vessels, and nerves should be performed with appropriate microsurgical expertise. Functional outcomes are variable with such replantation efforts, largely reflecting the condition of the severed organ and the time that elapses prior to replantation.

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FIGURE 36-36 Subtotal penile amputation injury due to assault with knife. (A) Photograph demonstrates complete transection of body of penis with right-sided skin bridge attaching distal phallus to body. Left testis is exposed as well. (B) Preparing for surgical reconstruction—minimal debridement of corpora cavernosa and urethra, following extensive irrigation. (C) Corpora cavernosal anastomosis has been completed; urethral anastomosis about to be completed after spatulation and mobilization of distal ends to avoid tension on repair. Following completion of urethral repair over Foley catheter, microsurgical anastomosis of deep dorsal arteries, deep dorsal vein, and adjacent nerves was performed (not shown).

Scrotal trauma should be explored if there is a concern about testicular rupture. In blunt trauma, testicular ultrasound may be helpful in deciding if operation is indicated. In penetrating trauma, we often utilize an oblique upper scrotal incision that provides access to the groin, spermatic cord, penile base, and scrotal contents. Most scrotal injuries should be explored with the goal of evacuation of the hematoma, debridement of devitalized tissue, and repair and salvage of the testicle (Figs. 36-37 and 36-38). Reproductive outcomes are favorable following such management.96

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FIGURE 36-37 Testis: testicular rupture due to blunt trauma. (A and B) Appearance of ruptured testis at surgical exploration following blunt trauma to scrotum. Note laceration of tunica albuginea with extruded seminiferous tubules. (C) Appearance of testis following minimal debridement of testicular parenchyma and repair of tunica albuginea with running 3-0 Vicryl suture.

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FIGURE 36-38 Scrotal exploration and testicular repair following gunshot wound to scrotum. (A) Entrance wound visible lateral to base of penis on left, exit just to the right of the median raphe; note marked left hemiscrotal swelling from hematoma. Surgical exploration is mandatory and preoperative scrotal imaging is unnecessary. (B) Scrotal exploration performed through high oblique scrotal incision for optimal exposure of scrotal contents and possible extension to groin if further spermatic cord exposure proves necessary. Entrance into tunica vaginalis visible. Testis introduced out of scrotum on spermatic cord pedicle. (C) Appearance of left testis demonstrating complex laceration of tunical albuginea with extruded testicular parenchyma. (D) Appearance of testis following limited parenchymal debridement and reconstruction of tunica albuginea. Testis is then returned to scrotum following evacuation of hematoma and extensive irrigation; Penrose drain placed through inferior stab incision in left hemiscrotum (not shown).

Cases of scrotal and other soft tissue loss in the genital region should be managed with a conservative approach to debridement of marginally vascularized skin and soft tissues as previously described. Delayed primary closure or reconstruction of significant scrotal loss using meshed split-thickness skin grafting produces favorable results. Human bite wounds have a very high infection rate and should be left open if presenting in a delayed fashion (see Chapter 49).

COMPLICATIONS OF GENITOURINARY TRAUMA

The management of complications of urologic injury is an important issue facing the trauma surgeon. Extensive reviews of this topic are available.9799 Complications may be categorized as early and late occurrences and can occur in the setting of an early diagnosis of injury or a delayed diagnosis of injury. Early complications of injury to the upper urinary tract include bleeding, postinjury infections, problems related to urinary extravasation, and ischemic processes. Renal and ureteral injuries may also result in late complications including hypertension, hydronephrosis, and renal insufficiency. Functional abnormalities following trauma to the urinary tract may include a neurogenic bladder, urethral stricture, and sexual or reproductive dysfunction. Appropriate follow-up studies for high-risk injuries are critical in the early detection of complications of urologic trauma.

DAMAGE CONTROL PRINCIPLES IN GENITOURINARY TRAUMA

Damage control surgery, or the process of intentionally delaying surgical interventions for lesions that are not immediately life-threatening, is an evolving strategy that is applicable to all surgical specialties.100102 With the exception of major, active bleeding from the kidney or renal pedicle, virtually any urologic injury can be handled in a delayed fashion without exposing the patient to significant risk. If the patient becomes stable, interval imaging (generally with contrast-enhanced CT or with arteriography if performed for another purpose) of a renal injury may allow selection of definitive nonoperative management. This avoids the time and potential morbidity of an unnecessary renal exploration at the second operative procedure. If, at the initial operation, bleeding from the kidney is not a major concern or hemostasis for significant bleeding has been obtained, the kidney can be packed. Renal reconstruction is then performed at a secondary laparotomy.

Ureteral injuries for which delayed management is necessary can be managed with externalized stenting (Fig. 36-39). A single-J urinary diversion stent can be passed up into the kidney through the lacerated or transected ureter, tied or sutured to the end of the proximal segment of ureter, and then externalized and attached to a drainage device. At secondary exploration, formal ureteral reconstruction can be completed. Alternatively, the injured ureter can be ligated or simply left to drain in situ, although these approaches have the disadvantages of either creating an obstruction or allowing urine to pool in the abdomen and increasing the risk of a postoperative infection.

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FIGURE 36-39 Patient managed with damage control laparotomy: gunshot wound to abdomen with injuries to small bowel, left iliac artery and vein, and left ureter. Patient was hemodynamically unstable following vascular repair, so ureteral injury was managed with damage control approach. Single-J stent was passed up proximal ureter at injury site and secured to end of ureter with silk tie; stent was externalized, exiting from left lower quadrant, as shown. Abdomen was closed with “Bogota bag” silo due to bowel and mesenteric edema. On return to operating room at 36 hours postinjury, formal ureteral repair with psoas hitch and ureteroneocystostomy was performed.

Certain bladder injuries may be difficult to repair at the initial operation as well. Visibility may be compromised by pelvic bleeding requiring packing, the complexity of the repair may require more time and blood loss than the patient can tolerate, or the degree of debridement needed may be unclear, as may be the case with a high-velocity gunshot wound. Delaying definitive repair may be accomplished by inserting bilateral externalized ureteral stents. The pelvis can then be packed for bleeding, compressing the open bladder against the pubis. Alternatively, placing an externalized suprapubic catheter (Malecot or Foley) within the injured bladder is also an option. If the catheter prevents tamponade of pelvic bleeding, it can be clamped temporarily and then reopened to drainage when the patient’s coagulopathy is corrected. The use of damage control principles for complex penetrating pelvic trauma in the battlefield setting has been recently reported. In this series, 43% of patients had urologic injury while 50% had major vascular injury. A 21% mortality rate in the first week postinjury was reported, while 36% of patients with combined vascular and rectal injuries died.103 A staged, multidisciplinary approach to management and reconstruction was shown to be valuable in this experience.

Injuries to the urethra and external genitalia can be temporarily managed with suprapubic catheterization or dressing applications pending the patient’s return to surgery for definitive management.

The results of damage control management for urologic injuries in appropriately selected patients appear to be acceptable in terms of patient survival, renal salvage, and functional outcome.104,105

CONSULTATION AND INTERSERVICE INTERACTION

A specialty service such as urology offers skills that are different from those of the general surgeon. These include endoscopic capability and familiarity with reconstruction of the urinary tract in the elective setting. The urology service should be informed of signs of urologic injury as early as possible, preferably from the emergency department. This allows the urologist to be involved in preoperative imaging and interpretation, later operative sequencing, and use of damage control strategies. The experience of large trauma centers in which an interested and capable urologic trauma team is involved often results in reduced rates of nephrectomy and improvements in other outcome measures.

MEDICOLEGAL CONSIDERATIONS

Urologists frequently become involved in the management of injuries that were not diagnosed at the initial operation. These are often recognized later in a patient’s clinical course, often after a complication (urinary extravasation, bleeding, azotemia, sepsis) initiates further testing and imaging studies. In this setting, it is important to communicate to the patient and family what is occurring and to document the events that have occurred in the medical record. It is important to educate patients and their families that traumatic injuries are complex and that certain complications are common and to be expected. Also, functional outcomes may be disappointing to patients.

In urologic reconstruction, internal stents may be utilized, and patients may be discharged with indwelling catheters that may be invisible and/or require regular attention to avoid complications. As patients with internal stents placed in the trauma setting may be lost to follow-up, it is important that specific instructions be given to a patient regarding outpatient care and for a date of return to the clinic. If a nephrostomy tube must be changed after being in place for a month, it is best to arrange for this intervention prior to discharge. Also, it is important to explain and document the potential consequences of neglecting internal tubes, including calcification and obstruction. As it is important to monitor a patient for hypertension for 2 years following certain major renal injuries, this should be explained and documented as well.

CONCLUSION

Much of the current consensus on approaches to genitourinary injury is based on retrospective studies. In fact, there are very few prospective studies in the urologic literature, leaving levels of evidence at a suboptimal state for evidence-based medical practice. Nevertheless, attempts at achieving a broad international consensus regarding the management of urologic injuries are ongoing.16 Important developments in body imaging, endoscopic approaches, endovascular stenting, and other radiologic and minimally invasive techniques have changed approaches to urologic trauma and selection of patients for operative versus nonoperative management. Further research will continue to impact the urologist’s role and approach in dealing with genitourinary injury (Fig. 36-40).

image

FIGURE 36-40 Algorithm for management of penetrating injury, proximity to lower urinary tract (bladder, lower ureters, urethra).

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