Upper Genitourinary Trauma Workup

• Complete blood count (CBC) to obtain hematocrit level and platelet count
• Prothrombin time (PT) and activated partial thromboplastin time (aPTT) to check for coagulopathy; may be unnecessary in young, otherwise healthy patients
• BUN and serum creatinine: Elevation of BUN without elevation in creatinine indicates urine reabsorption.
• Urinalysis to diagnose hematuria
• Blood type and crossmatch

Use of diagnostic imaging techniques is crucial in functional and anatomic assessment of the injured and uninjured kidney.

Perform urologic imaging only when indicated, as persistent low yield occurs when imaging patients with microscopic hematuria, patients with no associated injuries, and patients who are hemodynamically stable.

Indications for imaging include the following:

• Gross hematuria
• Microscopic hematuria with hemodynamic instability
• Persistent microscopic hematuria (serial urine analysis)
• Hemodynamic instability with history of significant deceleration mechanism

CT scan of the abdomen and pelvis with IV contrast

• CT scan is preferred over intravenous pyelogram (IVP) in renal injuries because of its superiority in providing anatomic and functional details, its higher sensitivity, and improved time to results with the advent of the spiral CT techniques. Multidetector CT scanners offer even greater image resolution and the ability for a CT angiogram of the kidneys.
• CT scanning allows visualization of the rest of the abdomen for detection of urinomas.
• Microscopic hematuria without hemodynamic instability or significant mechanism is not an indication for CT scan in patients with blunt trauma.
• Perform CT scan if a history of hypotension; gross hematuria; or penetrating abdominal, flank, or back injury is present in the stable patient.
• Renal pedicle thrombosis may present without hematuria, but associated injuries or findings usually mandate CT scan or laparotomy. See the image below. CT scan of abdomen and pelvis showing a urinoma.

Intravenous pyelogram

• IVP provides information about the function of both kidneys; when performed with a double dose, it is the preferred test in suspected ureteral injuries.
• In renal injuries, CT scanning is preferred due to the relatively poor sensitivity of IVP.
• If CT scan is not readily available and renal imaging is required, IVP is a good imaging study to perform as a first-line modality.
• CT scan or laparotomy should follow an abnormal IVP finding.

Renal arteriography

Use renal arteriography when therapeutic embolization is needed and to determine regional blood flow to the affected kidney if considering exploration.^[1]

Ultrasonography

Ultrasonography is inferior to CT scan in anatomic detail and sensitivity.

It may be helpful in follow-up care of renal injuries and in detection of urinomas.

Ultrasonography may also be useful in the acute setting of abdominal trauma as part of the focused abdominal sonography in trauma (FAST) examination of the injured patient in detecting perirenal hematomas and other injuries to the abdomen.

Other

Radionuclide scan is not helpful in diagnosis of renal injury but is useful in follow-up treatment regarding the function of the injured kidney.

Retrograde ureterogram is useful in diagnosing ureteral injury, especially in missed injury. It is invasive and requires a cystoscopy suite.

See the image below.

• Insert a Foley catheter only after urethral injury is excluded.
• A suprapubic cystostomy may be performed in a percutaneous or open manner when a Foley catheter cannot be inserted and urine output measurement or detection of hematuria is required.
• Use a suprapubic cystostomy when Foley catheter insertion is contraindicated.