Injuries to Genito-Urinary Tract

dr. Ramlan Nasution, Sp.U / dr. Yacobda H. Sigumonrong, Sp.U

Urology Division, Department Of Surgery

Faculty Of Medicine
University Of Sumatera Utara
Learning Objective
 Mengetahui etiologi
 Mampu menjelaskan klasifikasi injury / cedera
 Mampu mendiagnosa secara klinik berdasarkan anamnesis, pemeriksaan fisik, lab
dan Radiologi
 Mampu menjelaskan penatalaksanaan
 Mampu merujuk ke spesialis
Renal injury

Ureteral injury

Bladder injury

Urethral injury

Injury to external genitalia

Standar Kompetensi Dokter Indonesia (SKDI)
No Topik Tingkat Tingkat Kemampuan
Kompetensi
1 Renal injury • Mendiagnosis,
2 Ureteral injury • Melakukan
Penatalaksanaan Awal,
3 Bladder injury 3B • Merujuk (Gawat Darurat)
4 Urethral injury
5 Injury to external genitalia

Lulusan dokter mampu :

• Membuat diagnosis klinik
• Memberikan terapi pendahuluan pada keadaan yang gawat darurat demi menyelamatkan nyawa atau
mencegah keparahan dan/atau kecacatan pada pasien
• Menentukan rujukan yang paling tepat bagi penanganan pasien selanjutnya.
• Menindaklanjuti sesudah kembali dari rujukan.
References
Renal Trauma
Renal Trauma
 Present in to up 5% of all trauma cases.
 Most common in young males
 Incidence of 4.9 per 100,000
 Most injuries can be managed non-operatively with successful organ
preservation
 Injuries commonly resulted from direct tissue disruption of the
parenchyma, vascular pedicles and collecting system
Etiology
Blunt injuries (80-90%)

• Multi Vehicle Accidents

• Falls
• Sporting injuries
• Assault

Penetrating injuries (10-20%)

• Stab wound
• Gunshot wounds
Renal trauma : Clinical findings
Symptoms
 Evidence of abdominal trauma
 Pain
 Hematuria
 Fractured ribs
 Abdominal distension
 Flank mass and tenderness
Signs
 Shocks
 Ecchymosis on flank region
Lab findings
 Microscopic or gross hematuria
Renal Trauma : Classification (AAST)

 The most commonly used classification system is that of the AAST

 Classification of high-grade injury  identifying the injuries most likely to benefit
from early angiographic embolization, repair or nephrectomy
Renal Trauma
: Classification
Renal Trauma : Evaluation
Indications for renal imaging
 Visible hematuria
 Non-visible hematuria and one episode of hypotension
 History of rapid deceleration injury and/or significant associated injuries
 Penetrating trauma
 Clinical signs suggesting renal trauma e.g. flank pain, abrasions, fractured ribs, abdominal
distension and/or a mass and tenderness.
Computed tomography is the imaging modality of choice in stable patients
FAST (Focused Assessment Sonography in Trauma)  identify hemoperitoneum as cause
of haemorrhage and hypovolemia
 Routinely used in primary survey
 Inferior to CT, insensitive, operator dependent, does not define the injury well
Renal Trauma : Evaluation (CT-Scan)
 Modality in stable patients
 Quick, widely available
 Accurately identify grade of renal injury
 Performed as three-phase study
 Arterial phase assesses vascular injury and presence of active extravasation of
contrast
 Nephrographic phase assesses parenchymal contusions and laceration
 Delayed phase imaging (5 minutes) identifies collecting system/ureteric injury

Grade 1 renal injury
Sub-capsular hematoma
Crescentic high-density fluid
collection around the left kidney.
Grade 3 renal injury
Renal laceration
Irregular non-enhancing renal
parenchymal defect with extension
greater than 1 cm deep to near the
renal pelvis..
Grade 2 renal injury
Sub-capsular and perinephric hematomas.
Defined fluid collection in the left perinephric
space and sub-capsular hematoma with
deformity of the renal parenchyma.
Grade 4 renal injury
Segmental infarction
Segmental area of non-enhancement in the
upper medial left kidney without associated
renal laceration
Grade 4-5 renal injury.
• Lacerations extending to the collecting system
• Deep lacerations extending into the collecting system of the
right kidney.
• Extension into the collecting system is confirmed by urinary
contrast extravasation on this delayed image through the
kidney in excretory phase.
Renal Trauma : Evaluation (IVP)

 Should only be performed when CT is not available

 One-shot intra-operative IVP
 Performed to confirm the presence of a functioning contralateral kidney in
patients too unstable to have had pre-operative imaging
 The quality of the resulting imaging is generally poor

 Technique
 Bolus intravenous injection of 2 ml/kg of radiographic contrast followed by a
single plain film taken after ten minutes.
Renal trauma : Management
Grade 1 - 3 Grade 4 Grade 5

• Managed • Mostly treated • Often present with

conservatively conservatively hemodynamic
(non-operative) • The requirement instability and
• Bed rest for subsequent major associated
• Serial blood tests intervention is injuries
• Regular observation higher • Higher rate of
exploration and
• Re-imaging as
nephrectomy
indicated.
Renal Trauma : Management
Indication for renal exploration
 A non- or transient-response to initial fluid resuscitation (Absolute
indication)
 Grade of injury (4-5)
 Transfusion requirements
 The need to explore associated abdominal injuries
 Discovery of an expanding or pulsatile peri-renal haematoma at
laparotomy
 Grade 5 vascular injury is an absolute indication
Renal Trauma : Surgical Management

• Goals  control of haemorrhage and renal salvage

• Stable hematomas detected during exploration
• Should not be opened
• Central or expanding hematomas
• Renal pedicle, aorta, or vena cava  potentially life-threatening and warrant
further exploration
• Renorrhaphy is the most common reconstructive technique
• Partial nephrectomy is required when non-viable tissue is detected.
Renal Trauma :
Summary
Ureteral Injury
Ureteral Injury
 1-2.5% of urinary tract trauma
 Rare as they are protected from injury by their small size, mobility, and
the adjacent vertebrae, bony pelvis and muscles
 Ureteral injury should be suspected in all cases of penetrating abdominal
injury, especially gunshot wounds, as it occurs in 2-3% of cases
 Mechanism
 External trauma : penetrating trauma (rare), high velocity
 Surgical trauma (Iatrogenic trauma)  Most common
Ureteral Trauma : Etiologies

Ureteral injury should be suspected in

• All cases of penetrating abdominal injury, especially
gunshot wounds
• Blunt trauma with a deceleration mechanism, as the
renal pelvis can be torn away from the ureter

More common in the upper ureter

Ureteral Injury : Diagnosis
• External ureteral trauma
• Severe abdominal and pelvic injuries.
• Penetrating trauma
• Associated with vascular and intestinal injuries
• Blunt trauma
• Associated with damage to the pelvic bones and lumbosacral spine injuries
• Hematuria is an unreliable and poor indicator of ureteral injury, as it is present in only
50-75% of patients
• Iatrogenic injury
• Noticed during the primary procedure
• Intravenous dye (e.g. indigo carmine) is injected to exclude ureteral injury.
Ureteral Injury : Diagnosis
 Multi-phase CT is the mainstay imaging technique for trauma patients.
 Widely available
 Allows for multi-phasic assessment of all of the structures in the pelvis and abdomen.
 Computed tomography urography (CTU) is the examination of choice when ureteral injuries are
suspected
 Extravasation of contrast medium in the delayed phase is the hallmark sign of ureteral trauma.
 Hydronephrosis, ascites, urinoma or mild ureteral dilation are often the only signs.
 Retrograde or antegrade urography
 Performed in unclear cases as confirmation
 Intravenous pyelography
 One-shot IVP, unreliable in diagnosis, as it is negative in up to 60% of patients
Ureteral Injuries : Management

Partial ureteral injuries Complete ureteral injury. Unstable trauma patients

• Stent or urinary diversion by a
nephrostomy tube.
• Stenting is preferred, provides
canalisation and may decrease the
risk of stricture
• Immediate repair is usually
advisable
• The ureter is mobilised on both
ends and a spatulated end-to-end
anastomosis is performed. However,
• ‘Damage control’ approach is
preferred
• Ligation of the ureter
• Diversion of the urine (e.g. by a
nephrostomy), and a delayed
definitive repair

Late-diagnosed injuries Wide debridement

• Nephrostomy tubeor a stent • Highly recommended for gunshot
wound injuries due to the ‘blast
effect’ of the injury.
Bladder Injury
Bladder Injury
 Motor vehicle accidents  most common cause of blunt bladder injury
 Falls and other accidents.

Mechanism
• The main mechanisms are pelvic crush and blows to the lower abdomen
• Most patients with blunt bladder injury have associated pelvic fractures (60-90%) and other intra-abdominal
injuries (44-68.5%)

EXTRAPERITONEAL INJURY INTRAPERITONEAL INJURY

Always associated with pelvic fractures
Distortion of the pelvic ring, with shearing of the
anterolateral bladder wall near the bladder base (at its
fascial attachments), or by a counter-coup mechanism
at the opposite side
Caused by a sudden rise in intra-vesical pressure of a
distended bladder secondary to a blow to the pelvis
or lower abdomen  the bladder dome is the
weakest point of the bladder and ruptures will
usually occur there
Bladder Injury :
Extraperitoneal vs Intraperitoneal
 Intraperitoneal Bladder Rupture
 Defect site : Dome / Upper part Bladder
 Cystogram : Contrast shown in bowel loops

 Extraperitoneal Bladder Rupture

 Defect site : bladder neck/prostatic urethra
 Cystogram : Contrast filled pelvic cavity and scrotum
Bladder Injury : Sign & Symptoms
 Visible hematuria
 Tenderness and swelling on suprapubic area
 Inability to void or inadequate urine output;
 Abdominal tenderness or distension due to urinary ascites, or signs of urinary ascites in abdominal
imaging;
 Uremia and elevated creatinine level due to intraperitoneal re-absorption
 Entry/exit wounds at lower abdomen, perineum or buttocks in penetrating injuries.
Bladder Injury : Diagnosis

Absolute indications for bladder imaging

 Visible hematuria and a pelvic fracture
 Non-visible hematuria combined with high-risk pelvic fracture
 Disruption of the pelvic circle with displacement > 1 cm

 Diastasis of the pubic symphysis > 1 cm

 Rami pubic fracture

 Posterior urethral injury

Bladder Injury : Imaging (Cystography)
 Cystography is the preferred diagnostic modality for non-iatrogenic bladder injury
 High sensitivity and sensitivity (90-95%) and specificity (100%)
 CT cystography is superior in the identification of bony fragments in the bladder
and bladder neck injuries, as well as concomitant abdominal injuries
 Mechanism
 Cystography must be performed using retrograde filling of the bladder with a minimum volume
of 300-350 mL of dilute contrast material
 Intraperitoneal extravasation  free contrast medium in the abdomen outlining bowel loops or
abdominal viscera
 Extraperitoneal extravasation  flame-shaped areas of contrast extravasation in the peri-
vesical soft tissues.
Intra-peritoneal Bladder Rupture in
Plain Cystography
Extra-peritoneal Bladder Rupture in Plain Cystography
Intra-peritoneal Bladder Rupture in CT Cystography
Extra-peritoneal Bladder Rupture in CT Cystography
Indications for Immediate Repair of Bladder
Injury
 Intraperitoneal injury from external trauma
 Penetrating or iatrogenic non-urologic injury
 Inadequate bladder drainage or clots in urine
 Bladder neck injury
 Rectal or vaginal injury
 Open pelvic fracture
 Pelvic fracture requiring open reduction and internal fixation
 Selected stable patients undergoing laparotomy for other reasons
 Bone fragments projecting into bladder
Management : Intra-peritoneal Bladder
Injury
 Exploratory laparotomy is performed to find the ruptured site and probable other
organ injuries
 Debridement and refreshing of wound edges is performed on the defect site
 Intra-peritoneal (abdominal) cavity washed, and the wound was sutured with 2
layers
 Cystostomy was placed from sutured site
Management : Extra-peritoneal Bladder Injury
 Mostly treated conservatively
 Indication for surgery :
 Bladder neck involvement
 Bone fragments in the bladder wall
 Concomitant rectal or vaginal injury
 Entrapment of the bladder wall surgical intervention
 Ruptured site should be sutured during surgical exploration for other injuries
 Decrease the risk of complications
 Reduce recovery time
Management : Extra-peritoneal Bladder
Injury
 Conservative management
 Clinical observation
 Continuous bladder drainage  Use catheter for 7-10 days
 Cystography before removing catheter
 Antibiotic prophylaxis
 If extravasation was found after 10 days of catheter placement, use of catheter
could be extended to 21 days.
Urethral Injuries
 Urethral
Injuries

Anterior Posterior
Anterior Urethral Injuries
 Iatrogenic injury  the most common type of urethral trauma
 Creation of a false passage by the tip of the catheter

 Inadvertent inflation of the anchoring balloon in the urethra

 Removal of the catheter with the anchoring balloon not fully deflated
 Straddle injuries or kicks to the perineum.
 Intact Buck’s fascia  blood & urine remain within the penis  Sleeve Hematoma
 Disrupted Buck’s fascia  blood & urine can spread to the scrotum, abdominal wall,
perineum and thigh
 Extravasation into the perineum  Butterfly Hematoma
Posterior Urethral Injuries
 Almost exclusively related to pelvic
fractures with disruption of the pelvic
ring
 Referred to as pelvic fracture urethral
injuries (PFUI)
 Mainly caused by MVAs
 Divided into partial or complete ruptures
(73% is complete, 27% partial)
 Triad:
 Blood at the meatus (Meatal Bleeding)
 Inability to urinate
 Full bladder
Urethtral Injuries : Clinical Signs

Anterior Urethral Injuries Posterior Urethral Injuries

 History of direct perineal trauma / straddle injury  Blood at meatus
 Blood at meatus  Gross hematuria
 Perineal and/or scrotal swelling & ecchymosis or  Perineal ecchymosis or hematoma (GU diaphragm
tenderness is disrupted)
 Penile hematoma  Scrotal or penile hematoma
 Inability to void  Difficulty passing a foley catheter
 Distended bladder and inability to void
 Non palpable prostate
Sleeve Hematoma ‘Butterfly’ Hematoma
Meatal Bleeding
Urethral Injuries : Diagnosis
(Urethrography)
 Standard in the early evaluation of a male urethral injury
 Conducted by injecting 20-30 mL of contrast material while occluding the meatus.
 Any extravasation outside the urethra is pathognomonic for urethral injury
 Incomplete rupture  extravasation from the urethra which occurs while the bladder
is still filling
 Complete rupture  massive extravasation without bladder filling
 RUG is able to reliably identify the site of injury (anterior vs. posterior), but the
distinction between a complete and partial rupture is not always clear
Partial Rupture Complete Rupture
Anterior Urethral Injuries : Management

Immediate exploration and urethral reconstruction

 Indicated for penile fracture related injuries and non-life threatening penetrating injuries
 Small lacerations can be repaired by simple closure
 Complete ruptures without extensive tissue loss are treated with anastomotic repair
Urinary diversion
 Suprapubic diversion or a trial of early endoscopic re-alignment with transurethral
catheterization
 Urinary diversion is maintained for one to two and three weeks for partial and complete
ruptures, respectively
Posterior Urethral Injuries : Management
 Mostly associated with other severe injuries
 Resuscitation and immediate treatment of life-threatening injuries have absolute
priority
 There is no urgency to treat the urethral injury and urinary diversion is
not essential during the first hours after trauma
 It is preferable to establish early urinary diversion to
 Monitor urinary output
 Treat symptomatic retention if the patient is still conscious;
 Minimize urinary extravasation and its secondary effects, such as infection and
fibrosis
Insertion of a suprapubic catheter
 It is an accepted practice in urgent situations
 An attempt (single attempt) at urethral catheterization can be carried out only by
experienced personnel.
 It is extremely unlikely that the gentle passage of a urethral catheter will do any
additional damage
Early urethral management (less than six weeks after injury)
 Immediate Urethroplasty (within 48h after surgery)
 Early Urethroplasty (2d to 6w after injury)
 Early Re-alignment
Deferred management (greater than three months after injury)
 Deferred Urethroplasty  Standard treatment
Injury to External Genitalia
 External Genitalia

Penis Scrotum

Penile Fracture Scrotal Injury

Penile Amputation Testicular Rupture

Penile Fracture
 The most important presentation of blunt penile trauma
 Causes :
 Sexual intercourse (most common)
 Forced flexion (taqaandan)
 Masturbation
 Rolling over
 Penile fracture is caused by rupture of the cavernosal tunica albuginea, and may be associated with
subcutaneous haematoma and lesions of the corpus spongiosum or urethra
 History :
 Sudden cracking or popping sound, pain and immediate detumescence.
 Local swelling of the penile shaft
 Enlarging hematoma.
 Bleeding
Penile Fracture : Management

 Tunica albuginea is more vulnerable to traumatic injury

 When a penile fracture is diagnosed, surgical intervention with closure of the tunica
albuginea is recommended
 It ensures the lowest rate of negative long-term sequelae and has no negative effect on
the psychological wellbeing of the patient
 Approach : circumferential incision proximal to the coronal sulcus which enables
complete degloving of the penis and closure of the tunica using absorbable sutures.
Penile Amputation

 Cause : Self-emasculation (Psychosis), Iatrogenic (circumcision)

 Goal of Management : cosmetic & functional
 Early management :
 The severed penis should be washed with sterile saline, wrapped in saline-soaked gauze,
and placed in a sterile bag and immersed in iced water.
 The penis must not come into direct contact with the ice.
 A pressure dressing or a tourniquet should be placed around the penile stump to prevent
excessive blood
 Surgical re-implantation should be considered for all patients and should be performed
within 24 hours of amputation
Scrotal Injury

 All penetrating scrotal GSW demand prompt surgical exploration

 The goal is testis preservation to maintain androgen production and cosmesis.
 Fertility is not commonly preserved
Testicular Rupture

 Found in approximately 50% of cases of direct blunt scrotal trauma

 It may occur under intense compression of the testis against the inferior pubic ramus or
symphysis, resulting in a rupture of the tunica albuginea.
 A force of approximately 50 kg is necessary to cause testicular rupture
 Symptoms :
 Immediate pain, nausea, vomiting, and sometimes fainting
 Hemiscrotum is tender, swollen, and ecchymosis.
 Testicle may be difficult to palpate
 Management : Surgical Exploration
 Involves exploration with evacuation of blood clots and hematoma
 Excision of any necrotic testicular tubules and closure of the tunica albuginea