Genitourinary Trauma

CHAPTER 30 Genitourinary Trauma

James M. Cummings, MD

What percentage of all hospital trauma admissions involve renal trauma?

Approximately 3%.

What percentage of all abdominal trauma involves the kidneys?

Approximately 10%.

True/False: The presence or absence of hematuria is not a good indicator of traumatic injury.

True. In one study, 13% of proven renal gunshot victims had no hematuria.

What are the indications for imaging of the kidneys following blunt trauma?

Gross hematuria or microhematuria combined with shock defined as systolic BP <90 at any time following the injury are absolute indications for genitourinary (GU) tract imaging.

In children, what are the indications for imaging of the kidneys following blunt trauma?

All children who sustain blunt trauma and have greater than 5 RBC per high-power field on a microscopic urinalysis or a positive dipstick should undergo radiographic assessment of the kidneys. Also, children with significant deceleration injuries (ie, falls from heights) may need renal imaging even in the absence of hematuria.

Staging of renal trauma is best accomplished with what radiographic test?

CT scanning of the kidneys provides detailed images of the kidneys that allow for a clear delineation of most renal injuries and their severity.

What are the advantages, if any, of an IVP over CT scans in the evaluation of GU trauma?

An IVP can be done in the operating room (OR) when needed during emergent exploration. However, CT gives a better assessment of the renal anatomy and permits diagnosis of concurrent injuries. Therefore, CT scans are the standard for trauma imaging of the kidneys.

The kidney is rich in tissue factor. What does this do and why is this important?

Tissue factor activates the extrinsic coagulation cascade that promotes hemostasis after an injury.

A small cortical laceration in the kidney with a small perirenal hematoma would be classified as what grade injury?

Grade II.

A renal injury extends through the parenchyma into the collecting system. What grade injury is this?

Grade IV.

What are the absolute indications for renal exploration following blunt trauma and how is it done?

An expanding or pulsatile retroperitoneal hematoma must be explored. Initial control of the involved renal pedicle prior to opening of the hematoma must be achieved by means of a retroperitoneal incision medial to the inferior mesenteric vein and anterior to the aorta. The dissection is carried cephalad until the involved renal pedicle is encountered. Vascular control is achieved and the hematoma can now be entered.

An attempt to repair a traumatic injury to the main renal artery should be pursued under what circumstances?

Repair of the main renal artery should be attempted only in a hemodynamically stable patient who has no other associated major organ system injuries, an ischemia time of less than 8 to 10 hours, bilateral renal injuries, or injury to a solitary kidney.

A patient has severe hematuria after a renal needle biopsy. What is the most likely diagnosis and treatment?

The most likely diagnosis is arteriovenous fistula. Angiographic arterial embolization is the preferred therapy.

The parents of a 12-year-old child with a solitary kidney want to know the risk of the child losing the remaining kidney in contact sports. What are the risk statistics you should tell them?

It has been estimated that 6 kidneys per 1 million children will be injured per year with only one kidney lost per 2.67 million children per year.

Hypertension following renal trauma can result from what 2 mechanisms?

1. Renal vascular injury leading to stenosis or occlusion of the renal artery or one of its branches.

2. Compression of the renal parenchyma from extravasated blood and urine (Page kidney).

A 1-cm segment of the left ureter is damaged during an elective left colectomy. The injury is recognized intraoperatively. The best choice for management at that time is?

Debridement of any devitalized tissue, mobilization of the 2 ends of the ureter, and a spatulated ureteroureterostomy over a stent. The area must be adequately drained postoperatively.

You are called to the OR to consult on a patient with a massive gunshot injury to the left abdomen. The trauma team has identified a 5-cm defect in the middle left ureter. The patient has become unstable and the trauma team wants to close and move the patient to the ICU for further resuscitation. What is your best option?

Ligate the proximal ureter and have a percutaneous nephrostomy placed when the patient has stabilized. Perform operative reconstruction at a later date when the patient is better prepared.

Does a ureteral injury sustained during an aortobifemoral grafting procedure require a nephrectomy?

No. In the past it was felt that with a 50% risk of mortality from graft infection, a nephrectomy was a safer option than reconstruction. However, with better stenting and diversion techniques, newer antibiotics, and improved graft materials, ureteral reconstruction can be performed as long as adequate diversion and drainage is done. The risk is also lowered if omentum or some other tissue barrier is placed between the graft and the ureter.

Which portion of the ureter is most likely to be injured during a hysterectomy?

The ureter is most likely to be injured at the level of the broad ligament where the ureter passes beneath the uterine vascular pedicle in close proximity to the cervix.

Following a ureteral reimplant with a psoas hitch, a patient complains of anterior thigh numbness. What is the most likely etiology for this complaint?

The genitofemoral nerve lies on the anterior aspect of the iliopsoas muscle. Injury to this nerve can occur during suturing of the bladder to the tendon of the psoas minor muscle resulting in numbness of the anterior ipsilateral thigh.

What are the options for closing a large gap between the proximal end of a damaged ureter and the bladder when a psoas hitch will not reach?

Initially, the bladder should be mobilized on the contralateral side to the injury. This often involves division of vascular structures (superior vesical artery, obliterated umbilical artery, etc). A Boari bladder flap can gain considerable length. Another option is to do a caudal nephropexy that can gain additional length to allow for closure of the defect. When these maneuvers are unsuccessful, a transureteroureterostomy can be performed in the patient with unprepared bowel, otherwise an ileal interposition graft may need to be employed.

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