NC.com

AAST renal injury severity, from AAST + Campbell's

Renal Trauma

CT findings concerning for major renal injury (9x more likely to require intervention)

1. Medial hematoma: suggests vascular injury
2. Medial urinary extravasation: suggests renal pelvis or UPJ avulsion
3. Global lack of parenchymal enhancement: suggests renal artery occlusion
4. Combination of 2+: large hematoma > 3.5cm, medial renal laceration, vascular contrast extravasation

Post-renal injury hypertension mechanisms (renin production stimulated by partial ischemia)

• Goldblatt kidney: renal artery injury leading to stenosis/occlusion
• Page kidney: compression of renal parenchyma with blood/urine
• Arteriovenous fistula: decreased renal perfusion due to diversion

Renal injury tips

• Prevalence: up to 34% have renal injury without hematuria or hypotension
• Venous injury: CT is not sensitive, have high suspicion in presence of medial hematoma
• Intraoperative IVP: confirms presence of contralateral kidney prior to performing trauma nephrectomy
• Embolization failure: seen in 13-88%, can repeat embolization
• Pseudoaneurysm: may develop in up to 2.5% renal trauma
• Fluid collections: urinoma (0-20 HU, delayed contrast pooling), hematoma (> 30 HU), abscess (rim enhancement + > 20 HU with contrast)
• During exploration, isolation/control of renal vessels prior to renal exposure no longer necessary
• Surgery tips: can attempt renal repair with debridement, suture ligation, closing collecting system and parenchymal defects, flaps, and drain placement

AAST ureteral injury severity, from AAST + Campbell's

Algorithm for ureteral injury from external trauma, from Campbell's

Algorithm for iatrogenic ureteral injury discovered intraoperatively, from Campbell's

Algorithm for iatrogenic ureteral injury discovered postoperatively, from Campbell's

Ureteral Trauma

Prophylactic stenting

• Does not decrease risk for injury, but improves chances of identifying injury
• Anuria risk with bilateral stents: 1-5% (place over a wire to minimize trauma)
• Ureteral injury during placement: 1%
• Inability to place stent: 13% unilateral, 2% bilateral

Ureteral repair principles

• Avoid ureteral devascularization
• Minimize debridement but assess for vascularity
• Perform spatulated, tension-free, stented, watertight anastomosis
• Close peritoneum if possible
• Place drain to evaluate for leak
• Do not tunnel ureteroneocystotomies
• Consider omental flap for severe injuries

Ureteral injury tips

• Remove catheter, then drain, to prevent urinoma formation
• Either repair immediately or delay repair for 6-8 weeks due to inflammation
• Distal injuries may require reimplantation
• Endoscopic iatrogenic injuries may heal with stenting alone
• Absence of hematuria and presence of bilateral jets is a poor predictor of injury, but can consider visualizing efflux of dye for confirmation

Bladder Trauma

Cystography tips

• Technique: fill w/ 300-350mL or to discomfort, do not fill passively with IV contrast
• XR Cystography: image at pre-fill, max fill, and after emptying, obtain 2-view images
• CT cystography: drainage films not required, dilute contrast 6:1 otherwise can create scatter artifact
• Findings: extraperitoneal injury with flame-shaped collection in pelvis, intraperitoneal injury with contrast outlining bowel loops

Bladder injury tips

• Hematuria: not always present (77-100%)
• Bladder rupture: > 90% will have gross hematuria, 0.6-5% will have microscopic hematuria only, seen with 29% patients with pelvic fracture + gross hematuria
• Pelvic fracture: seen in 83-95% bladder injuries, but bladder injury present in 5-10% pelvic fractures, suspect if circle displacement > 1cm, pubic symphysis diastasis > 1cm, or pubic rami fracture
• Unrecognized bladder injury signs: acidosis, azotemia, fever, sepsis, low UOP, peritonitis, ileus, ascites, respiratory distress, incontinence, fistula, stricture

Surgery tips

• Principles: place catheter, inspect bladder neck and ureteral orifices for injury, minimize debridement, close with absorbable suture, perform leak-test
• Simultaneous vaginal/rectal injury: place omental flap or other interposition to prevent fistula
• Catheter duration: obtain cystogram 10-21 days after surgery to assess for leak

Urethral Trauma

Retrograde urethrogram instructions

1. Bottom leg flexed, top leg straight, oblique angle
2. Small catheter placed in meatus (12Fr)
3. Gentle traction, inject 20mL undiluted contrast
4. If catheter already placed, use 3Fr catheter next to indwelling catheter

Urethral injury tips

• Pelvic orthopedic repair: NOT a contraindication to SPT placement
• Delayed repair: perform 2-3mo after injury (stable scar tissue), evaluate with simultaneous urethrogram and VCUG
• Primary realignment: high risk for stenosis, place and maintain SPT, can remove 1-2 weeks later
• Endoscopic stricture management: rarely successful
• Long term management: monitor for ED (50-82%), strictures (5-15%), incontinence (< 4%) for at least 1yr after injury

Penile Trauma

Fractures

• Diagnosis: suspect when bruising/edema, reported "pop" with immediate loss of erection, obtain US if diagnosis equivocal
• Taqaandan: self-inflicted fracture, penis forcibly bent during masturbation as a method to achieve rapid detumescence
• Management: can take to OR on clinical evidence alone, imaging not required, US preferred for equivocal findings
• Incision: make ventral incision (most common fracture location), localized incision over hematoma, or subcoronal incision
• Urethral injury: can perform intraoperative cystoscopy or preoperative urethrography (time-consuming)
• Close tunical defects with 2-0 or 3-0 absorbable sutures, smaller for urethral injury
• Mimics: rupture of dorsal penile artery, dorsal penile vein, or suspensory ligament
• Surgical delay: up to 7 days does not adversely affect repair results
• Preventing postop erections: consider benzodiazepines, amyl nitrate, or ketoconazole

Penetrating trauma

• Management: exploration, irrigation, excision, surgical closure, antibiotics
• Urethral injuries: can be identified with urethrography or pericatheter dye injection, can repair primarily
• Animal bites: irrigation/debridement, antibiotics (augmentin, cefoxitin, clindamycin + quinolone), do not close human bite wounds primarily

Amputation

• Psychosis: present in 65-87% patients, always consult psychiatry
• Ischemia time: successful if within 16hr for cold or 6hr for warm
• Double bag: wrap in saline-soaked gauze, place in bag, place in second bag with ice
• Microscopic repair: not required to anastomose and regain erectile function, but has less risk for strictures, skin loss, and sensory loss (20% vs 90-100%)
• Skin necrosis: high risk due to loss of blood supply
• Technique: SPT placement, close tunica with absorbable 2-0, close urethra with absorbable 4-0, dorsal artery with 11-0 nylon, dorsal vein with 9-0 nylon, dorsal nerve with 10-0 nylon, skin coverage

Zipper injuries

• First tricks: perform penile block, lubricate with mineral oil, attempt to unzip
• Second tricks: cut cloth between each individual tooth to release support and have zipper fall apart
• Third tricks: consider cutting median bar of zipper with a bone cutter or wire cutter, or screwdriver to pry apart top and bottom

Strangulation injuries

• Examine any idiopathic penile swelling for hidden hair or string
• Attempt reduction of distal edema with penile wrap
• String reduction technique: useful if able to thread string under constricting device, can also puncture glans to drain edematous blood/fluid
• Can incise plastics with scalpel or cast saw
• Metal items may require industrial cutting devices, including from fire or EMS services, perform in OR under anesthesia
• Consider suprapubic tube if patient unable to void and removal delayed

Scrotal/Testis Trauma

Rupture

• Scrotal US: assess for hematoma, incongruity of tunica albuginea, loss of contour, heterogenous parenchyma
• Indications for OR exploration: penetrating injury, scrotal US unable to rule out rupture, hematoma actively enlarging or > 5cm
• Technique: debride extruded tissue, close with 4-0 absorbable suture, consider drain placement, perform orchiectomy if non-viable appearance
• Success: 80-90% salvage rate if explored within 3 days of injury, 32-65% salvage rate for penetrating trauma
• Dislocation: due to high-impact trauma to scrotum, consider imaging with US/CT to find testis if empty hemiscrotum present on exam, explore via inguinal incision and perform orchiopexy

Scrotal skin loss

• Debride non-viable tissue and attempt primary closure
• Thigh pockets: consider on loss of > 50-60% scrotal skin
• Skin grafting: split thickness preferred
• Deep electrical burns: manage conservatively, often leads to autopenectomy or death due to severity of total injuries

Scrotal hematoma/hematocele

• Prevalence: 80% hematoceles are caused by testis rupture and should be explored
• Hematocele: small collections can be observed, otherwise explore if large or persistent bleeding to prevent infection, testicular compression, prolonged pain
• Cutaneous hematoma management: ice, elevation, scrotal support
• Intratesticular hematoma management: difficult to distinguish from testis rupture, therefore requires scrotal exploration, can re-image in 4-6 weeks to assess for resolution (vs concern for testis tumor)

References

• Brandes, S. and J. Eswara. "Upper Urinary Tract Trauma." Campbell-Walsh Urology 12 (2020).
• Morey, A. and J. Simhan. "Genital and Lower Urinary Tract Trauma." Campbell-Walsh Urology 12 (2020).
• Morey, Allen F., et al. "Urotrauma Guideline 2020: AUA Guideline." The Journal of Urology 205.1 (2021): 30-35.
• Wieder JA: Pocket Guide to Urology. Sixth Edition. J.Wieder Medical: Oakland, CA, 2021.