Upper Genitourinary Trauma Treatment & Management

Updated: Jan 24, 2017
  • Author: Imad S Dandan, MD; Chief Editor: Trevor John Mills, MD, MPH  more...
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Treatment

Prehospital Care

Advancement of prehospital care for trauma patients is one of the biggest leaps forward in trauma care. Principles do not change with different organ injuries.

Paramedics quickly assess the patient and mechanism of injury, with special attention to patency of ABCs.

  • Establish an airway if needed and/or administer oxygen.
  • Establish 2 large-bore IVs.

Take cervical spine precautions (eg, hard collar, back-board).

Quickly transport the patient to the trauma center.

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Emergency Department Care

Adherence to ATLS principles is necessary for proper care of the trauma patient.

  • Administer oxygen and ventilatory support if needed.
  • Resuscitate with crystalloids (lactated Ringer solution or isotonic sodium chloride solution) and blood (O-negative or type-specific blood if known) if indicated.
  • Treat life-threatening injuries (eg, tension pneumothorax, open pneumothorax, cardiac tamponade) should be addressed emergently in the ED.

Assess capabilities of the ED to handle the patient with multiple injuries that include upper GU trauma; the decision to transfer is based on that assessment.

Treat life-threatening injuries prior to transfer; stabilize and resuscitate the patient.

The responsibility for transfer, choice of transfer modality, and selection of accepting facility lies with the transferring physician.

The receiving physician confirms the ability of the receiving institution to handle the patient's condition.

Institutional transfer protocol facilitates the process.

Patients with upper GU trauma benefit from transfer when the following conditions exist at the transferring center:

  • CT scan not available
  • No staff urologist
  • Multiple injuries that surpass hospital's resources
  • Unavailability of specialized care required by patient's injuries
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Consultations

Consultations include the following:

  • Trauma or general surgeon for management of associated abdominal injuries
  • Urologist for management of specific GU injuries
  • Other specialists as injuries dictate
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Medical Care

Management of renal injuries depends on the grade of injury and is linked to management of associated injuries. [11, 12]  Grade of renal injury is best depicted in the scale developed by the American Association for the Surgery of Trauma [13, 14, 15]

Grade I

Grade I injuries include the following:

  • Contusion - Microscopic or gross hematuria with normal urologic studies
  • Hematoma - Subcapsular, nonexpanding without parenchymal laceration

Grade II

Grade II injuries include the following:

  • Hematoma - Nonexpanding and confined to the renal retroperitoneum
  • Laceration - Less than 1 cm parenchymal depth of renal cortex without urinary extravasation

Grade III

Grade III injuries include the following:

  • Laceration more than 1 cm parenchymal depth of renal cortex without collecting system rupture or urinary extravasation

Grade IV

Grade IV injuries include the following [15] :

  • Laceration - Extending through the renal cortex, medulla, and collecting system
  • Vascular - Main renal artery or vein injury with contained hemorrhage

Grade V

Grade V injuries include the following:

  • Laceration - Completely shattered kidney
  • Vascular - Avulsion of renal hilum that devascularizes the kidney

Treat grades I, II, and III conservatively. Monitor vital signs, hematocrit level, and progression of hematuria. Most patients heal without intervention. Rarely, radiologic selective embolization is needed to control hematuria that does not subside spontaneously.

In grade IV injuries, expectant treatment of the extravasation has a 60% success rate if ureteral outflow is not impeded. Correct flow obstruction with stenting. If urinary extravasation does not improve, perform percutaneous drainage. Vascular injury indicates surgical intervention for repair, provided the warm ischemia time does not exceed 4 hours. Hemorrhage control also indicates surgical exploration.

Most children with grade IV renal injury are treated using a conservative approach with a high success rate, but some may require urologic intervention because of symptomatic urinomas. According to one study, the need for transfusion and the presence of specific image features on initial CT (eg, main laceration location in the anteromedial portion of kidney), intravascular contrast extravasation, and a large perinephric hematoma may serve as useful predictive factors for urologic intervention in grade IV pediatric blunt renal trauma patients who were initially treated with a conservative approach. [16]

In grade V injuries, completely shattered kidneys require excision for control of hemorrhage. Kidneys with pedicular avulsion do not require removal unless a laparotomy already is being performed for a different pathology. Avulsed kidneys do not result in late sequelae if left in situ. Attempt revascularization of the kidney only if warm ischemia time is less than 4 hours, as failure rates are extremely high when warm ischemia time is more than 4 hours. High rates of infection and hypertension occur in kidneys with failed revascularization. Make exceptions for patients with solitary kidneys and decreased renal capacity.

Management of acute ureteral injury primarily involves repair. Debridement is performed until a healthy bleeding ureter is reached and a repair is performed at this point by the surgeon. The type of repair depends on the level of ureter injury and the length of ureter lost to injury and debridement.

Treatment of ureteropelvic junction injuries is by reimplantation of the ureter into the renal pelvis. Ureteroureteral or ureterovesicular anastomoses are used for distal injuries and bladder flaps may be required for a tension-free anastomosis. Transureteroureterostomy (anastomosis of the injured ureter to the contralateral ureter) has lost favor because of danger to the normal ureter. Management of missed ureteral injuries includes drainage of urinomas (preferably percutaneously) with a nephrostomy. The inflammation is allowed to subside (3-6 wk), then a definitive surgical repair is performed.

Most children with grade IV/V renal injury following blunt trauma can be managed nonoperatively. Management can be properly planned and executed based on clinical features, CT imaging, and staging of renal injuries. [17]

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Complications

Renal trauma

Renal trauma includes the following:

  • Hemorrhage
  • Urinoma
  • Loss of function of kidney
  • Pseudoaneurysm formation
  • Arteriovenous fistula (rare)
  • Renal hypertension
  • Obstruction of the collecting system and renal artery aneurysm (pseudo)

Ureteral injury

Ureteral injury includes the following:

  • Urinary extravasation
  • Urinoma
  • Infection and stricture formation leading to hydronephrosis
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Long-Term Monitoring

Outpatient care depends upon the associated injuries and need for rehabilitation (eg, orthopedic or neurologic injuries).

A follow-up CT scan is indicated in patients with renal injuries to assess the progress of healing; IVP is required as follow-up care for ureteral repairs.

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