Editing Genitourinary tract trauma

== '''Kidney''' ==

* Approach
** Mostly non-op these days
** Operation reserved for complex, multiorgan trauma or penetrating trauma
** Primary objective is to stem life-threatening bleeding while preserving enough nephrons to avoid renal disease
* Diagnosis
** Indications for specific imaging (contrast CT with 10 min delay scans)
*** Blunt trauma with gross haematuria (microscopic haematuria is not an indication)
*** Blunt trauma, microscopic haematuria and shock
*** Any other concern for renal injury
*** Any paediatric trauma with any degree of significant haematuria (>50 RBC/HPF) should be imaged

{| class="wikitable"
|AAST Grade
|Imaging Criteria (CT Findings)
|-
|I
|Subcapsular hematoma and/or parenchymal

contusion without laceration
|-
|
|
|-
|II
|Perirenal hematoma confined to Gerota fascia
|-
|
|Renal parenchymal laceration ≤1 cm depth 

without urinary extravasation
|-
|III 
|Renal parenchymal laceration >1 cm depth without

collecting system rupture or urinary extravasation
|-
|
|Any injury in the presence of a kidney vascular injury

or active bleeding contained within Gerota fascia
|-
|IV
|Parenchymal laceration extending into urinary

collecting system with urinary extravasation
|-
|
|Renal pelvis laceration and/or complete

ureteropelvic disruption
|-
|
|Segmental renal vein or artery injury
|-
|
|Active bleeding beyond Gerota fascia into the

retroperitoneum or peritoneum
|-
|
|Segmental or complete kidney infarction(s)

due to vessel thrombosis without active bleeding
|-
|V
|Main renal artery or vein laceration or

avulsion of hilum
|-
|
|Devascularized kidney with active bleeding
|-
|
|Shattered kidney with loss of identifiable 

parenchymal renal anatomy
|}
''Vascular injury is defined as a pseudoaneurysm or arteriovenous fistula and appears as a focal collection of vascular contrast that decreases in attenuation with delayed imaging. Active bleeding from a vascular injury presents as vascular contrast, focal or diffuse, that increases in size or attenuation in delayed phase. Vascular thrombosis can lead to organ infarction.''

''Grade based on highest grade assessment made on imaging, at operation or on pathologic specimen.''

''More than one grade of kidney injury may be present and should be classified by the higher grade of injury.''

''Advance one grade for multiple injuries up to grade III.''

*

* Management
** Blunt
*** Grade I, II, III: non-op
*** Grade IV and V: generally non-op unless indications for intervention below
** Penetrating
*** Grade I, II, III: non-op provided no major blood loss, no major renal parenchymal injury, no renal vascular injury, no associated intra-abdominal trauma needing surgery
** Non-op strategies
*** Bed rest (may not be required)
*** Haemodynamic monitoring
*** Serial Hb
*** Repeat imaging if becomes unstable, or persistent gross haematuria
*** If high-grade injury, reimage with second CT urogram 3-5 days after injury to evaluate for persistent urine leak or urinoma
*** Large urine leaks should prompt indwelling stent placement
*** Leave an IDC to prevent urine reflux
*** Low threshold for Abx
*** Percutaneously drain large or infected urinomas
** Embolisation
*** It works, because no significant collateral - stops bleeding at the expense of nephrons
** Surgical
*** Indications
**** Absolute
***** Expanding pulsatile retroperitoneal haematoma
***** Renal pedicle avulsion
***** Persistent/life-threatening shock or haemorrhage
***** Ureteropelvic junction disruption or avulsion
**** Relative
***** Urinary extravasation without viable tissue
***** Concurrent colon/pancreas/trauma exploration with incomplete staging or grade III or greater concurrent renal injury
***** Renovascular hypertension
***** Failed embolisation
*** Indications for nephrectomy
**** Shattered kidney, major vascular laceration, unstable patient
*** Approach
**** Can be either proximal control first (supported by Cameron's as decreasing nephrectomy rate, particularly if there is a medial haematoma) or lateral-to-medial
**** Standard trauma laparotomy
**** Renal reconstruction should be attempted in a stable patient, with nephrectomy for patients needing damage control
*** Minor injuries
**** Renal pelvis lacerations - repair with fine absorbable sutures
* Complications:
** Urinoma, infected
** Ongoing/delayed haemorrhage
** Delayed bleeding
** Urinary fistula
** HTN (Page syndrome)
** Hydronephrosis


'''Simple nephrectomy:'''

* Medial visceral rotation on either left or right
* Incise Gerota's fascia laterally and bring kidney out of its bed
* Clamp vessels at hilum

'''Exploring a perinephric haematoma:'''

* Firstly, try not to do it, especially if the patient is stable.
* There is a process called 'midline looping' that allows you to slowly gain proximal control of the renal vessels as they come off the aorta
** Incise retroperitoneum over aorta superior to IMA, and extend to ligament of Treitz
** Continue opening retroperitoneum until left renal vein encountered, then loop it
** Use that vessel as a guide to find remaining vasculature, and loop that too


== '''Ureter''' ==

* Rare (1% of all genitourinary trauma)
* Aetiology
** Almost always penetrating trauma
** Mostly upper ureter
** Iatrogenic
*** Hysterectomy 0.5%
*** Endourologic procedures 1%
* Diagnosis
** If already in OT - direct inspection, followed by cystoscopy + retrograde pyelogram if necessary
** CT urogram - urinoma, urinary ascites, new hydronephrosis, extravasation of contrast from ureter
*** Complete avulsion - distal ureter will not fill
*** Partial tear - distal ureter will likely fill
*** Haematoma may indicate site of injury
** Fluid sample - check for creatinine
**
* Management
** Doesn't necessarily need to be fixed straight away, especially if multiple other injuries/unstable patient. 
** Need to drain urine somehow - if not draining through ureter, need nephrostomy
** Principles of surgical repair
*** Maintain ureteric blood supply
*** Tension-free anastomosis
*** Debride bleeding edge
*** 4-0 or 5-0 absorbable suture
*** Spatulate ends for primary repair - if the cut ends can be apposed without tension, they should be joined over a double pigtail catheter
*** Damage control - clip ureter proximal to injury and obtain percutaneous drainage
** Exam answers?
*** Primary closure with spatulation
*** Clip proximal end and transfer
**
* Complications
** Stricture - monitor for hydronephrosis with serial USS (to prevent renal disease secondary to asymptomatic obstruction)
** Uroma/infected abscess - treat with drainage and Abx

== Bladder injuries ==

* Intraperitoneal (20%) or extraperitoneal (80%)
* Presentation:
** Intraperitoneal - generally secondary to a blow or fall on a distended bladder, and rarely to surgical damage - sudden severe pain in the hypogastrium, often accompanied by syncope. Shock subsides, abdomen distends, no desire to micturate. Peritonitis does not follow immediately if urine is sterile.
** Extraperitoneal - caused by blunt trauma or surgical damage
* Diagnosis:
** CT is generally diagnostic
** Indications for retrograde cystography/CT cystogram:
*** Blunt pelvic trauma with gross haematuria (>30RBC/HPF)
*** Penetrating trauma with any haematuria
*** Other concern for bladder rupture
* Management
** Extraperitoneal rupture are generally conservative with catheter drainage, as long as the rupture is uncomplicated
** Indications for surgical repair
*** Intra-peritoneal bladder rupture in setting blunt trauma (likely large rupture)
*** Extra-peritoneal injury with open pelvic fractures, UTI, bony fragments, or foreign body in bladder
*** Bladder neck injury
*** Concomitant renal injury
*** Urethral injury
*** Major vaginal laceration
** Operation for extra-peritoneal rupture
*** Pfannenstiel incision
*** Primary closure
** Operation for intra-peritoneal injuries
*** Lower midline incision
*** Debride edges of hole
*** Suture with single-layer 2/0 absorbable according to Bailey and Love
*** Place suprapubic and urethral catheter
** If bladder injury identified during operation:
*** Primary repair
*** Catheter drainage
** Repair lacerations in a two-layer closure with running slowly absorbable suture. First layer is for mucosa/submucosa, and second layer muscularis and overlying serosa. Single layer is ok if access is difficult for neck laceration.
** Should have IDC afterwards (+ also SPC?)
** Follow-up imaging should be obtained whether operative or non-operative management at about 2/52, and start trial of void at that time


== '''Urethral injury''' ==

* Presentation (IDC contra-indicated)
** Blood at meatus
** Difficulty voiding after injury
** Palpable bladder
** Butterfly perineal haematoma
** High riding prostate on DRE
** Pelvic haematoma
** Associated bladder injury
* Classification
** Anterior vs posterior
** Partial vs complete
** Bladder neck injuries, or posterior injuries involving rectum or vagina, are 'complex'
* Retrograde urethrogram
** 8Fr IDC secured in the meatal fossa, with balloon inflated to 1.5-2mL, then 15-20mL of undiluted contrast is instilled with gentle pressure



[[Category:Trauma]]