Lina Choridah

Radiology Department
Faculty of Medicine, Public Health and Nursing UGM
RENAL INJURY
EPIDEMIOLOGY

• The most common urologic trauma

• 8-10% of patients with significant blunt or penetrating abdominal trauma

• In most cases, major renal injuries are associated with injuries to other major
organs.
 • Motor vehicle accidents

CAUSES AND • Fall from a height and assault, penetrating

ASSOCIATED injuriesà less common causes.
FEATURES
• Iatrogenic causes and renal masses
(eg, angiomyolipoma) à bleeding after a
minor trauma.
SIGNS and SYMPTOMS

• Hematuria (95%), flank hematoma, lower rib fractures, and vital sign
instability, such as hypotension.

• Hematuria may be nonexistent, especially with renal vascular injuries and UPJ
avulsion or ureteral injuries
• 1000 blunt abdominal trauma patients with only microscopic hematuria and
without hypotension à 1-5 have significant injury of the urinary tract

• Microhematuria alone is not an absolute indication for imaging.

 Ultrasound

IMAGING IVU

CT Scan
ULTRASONOGRAPHY
• Ultrasonography also has limited clinical usefulness in the
evaluation of renal trauma.

• The main application à Focused abdominal sonography for

trauma (FAST) scanning, with the goal of detecting any free
fluid in an unstable patient.
FAST
• The primary advantage to this technique is that it can be performed
in a matter of minutes in the trauma bay while a patient is being
resuscitated.

The presence of fluid is an indication for exploratory laparotomy by

surgeons.
 FAST (video)

RUQ free fluid LUQ free fluid SP free fluid

CEUS

• rarely used in the context of renal trauma.

• In select cases à or follow-up (e.g. to reduce ionizing radiation exposure).
• The renal cortex demonstrates a rapid and early enhancement normally, followed by that the
pyramids.
• Renal injuries such as lacerations à hypoenhancing areas, which are often wedge-shaped.
• Focal, patchy accumulations of contrast agent microbubbles are highly suggestive of active
bleeding.
• If both kidneys need to be interrogated two separate contrast agent boluses are recommended.
• CEUS does not detect collecting system injuries since the microbubbles remain intravascular 6.
CEUS
 Become more limited as CT has
become more available.

IVU
IVU may still be used if CT is not
readily available, for unstable patients
going to surgery or for urologic
imaging of a patient in the operating
room.
 a scout radiograph

immediately after the injection of contrast material

TECHNIQUE
10 min after the injection

additional delayed: to assess delayed excretion of

contrast material if present and to detect the presence of
urinary contrast extravasation.
 the loss of the renal outline or
psoas shadow àperinephric
hemorrhage, diminished or
absent excretion

FINDINGS
contrast extravasation.
 • evaluate ureteral injury /
displacement

THE • the presence of a contralateral

functioning kidney should be
URETERS confirmed in the event that
significant unilateral renal injury
warrants nephrectomy
 • May not always accurately specify the cause
or extent of renal involvement, while minor
vascular injury or urinary extravasation may
be missed.

DISADVANTAGES • Grade 1 or 2 renal injuries are not easy to

detect on the IVU.
OF IVU
• A nonvisualized kidney
(nephrogram/pyelogram) does not
necessarily represent significant renal
trauma
DEGREE OF CONFIDENCE
CT VS IVU

• IVU has lower sensitivity à renal injury and urinary contrast extravasation.

• IVU has lacks ability to detect nonurologic injuries

• Signs of hemoperitoneum on radiography are not sensitive or specific enough to be useful.

COMPUTED TOMOGRAPHY

• The most comprehensive diagnostic tool

• To evaluate a large breadth of intra-abdominal injuries with accuracy, and

hence, it has a primary role in evaluating the trauma patient.
• CT in staging abdominal injuries à nonoperative
management of traumatic abdominal injuries.

• Should be as close to the trauma bay as possible to

minimize patient transport time.

• MDCT has ability to depict injuries such as active

arterial extravasation.
AAST
Renal injury
Grading Scale
GRADE 1

• Contusion (arrowhead)

• Subcapsular hematoma (arrow).

Collecting system is intact.
GRADE 1
• Subcapsular hematoma.

• Crescentic high-density
fluid collection around
the left kidney.

• Well-defined outer
margin.
GRADE 2

• Non expanding perinephric hematomas

confined to the retroperitoneum

• Superficial cortical lacerations less than

1 cm in depth without collecting system
injury
GRADE 2
• Renal laceration.

• A superficial (less than 1

cm deep) renal
parenchymal defect with
a large perinephric
hematoma.
GRADE 2
• Delayed image of
same patient shows
no urinary contrast
extravasation.
GRADE 2
Subcapsular and
perinephric hematomas.
shows an ill-defined fluid
collection in the left
perinephric space.
There is also a
subcapsular hematoma
with deformity of the
renal parenchyma.
GRADE 2
• Perinephric
hematoma.

• ill-defined fluid
collection in the left
perinephric space.
GRADE 3
• Laceration larger than 1 cm
(arrowhead) extending into renal
parenchyma but not into collecting
system.
• Associated perinephric hematoma is
contained within Gerota fascia (short
arrow).
• Vascular injuries, including
pseudoaneurysms (long arrow) and
arteriovenous fistulas, can occur.

• Active bleeding may be seen in grade III

injuries.
GRADE 3
• shows very
diminished left
nephrogram and no
urinary contrast
extravasation.
GRADE 3
• shows irregular
nonenhancing renal
parenchymal defect
with extension > 1 cm
deep to near the
renal pelvis.
GRADE 3
• Delayed image
showed no
urinary contrast
extravasation.
GRADE 4

• shows combination of deep parenchymal lacerations

that involve calyces (arrowhead)
• vascular segmental injuries that can result in infarcted
renal segments (long solid arrow)
• laceration to renal pelvis (dashed arrow), and
ureteropelvic junction disruption (complete or
incomplete).
• Active bleeding may be present, and its distinguishing
feature is that hemorrhage can extend beyond Gerota
fascia (short solid arrow).
• One scenario (not shown) is vascular thrombosis
leading to global renal infarction, and this can be seen
without active extravasation being present.
GRADE 4
• renal injury
segmental infarction.

• Non enhancement in
the upper medial
left kidney without
associated renal
laceration.
GRADE 4
• Renal injury segmental
infarction.

• Non enhancement in the

upper medial left kidney
without associated renal
laceration.
GRADE 4

• Sonogram
• shows both kidneys
with an avascular
area in the lower half
of the affected
kidney.
GRADE 4
• Sonogram of the same
patient

• shows progressive
shrinkage of the lower
half as the kidney goes
ischemic autopartial
nephrectomy.
GRADE 5

• Disruption of main renal artery or

veins (including avulsion or
laceration [arrowhead])

• Main renal artery injury (arrow)

resulting in large perirenal
hematoma and devascularization.

• Shattered kidney (not shown),

another grade V injury

Complete laceration or thrombus of the main

renal artery / vein
GRADE 5
• Normal ultrasound
in gray-scale image
GRADE 5
• Color Doppler
ultrasound

• No blood flow
within the right
kidney.
GRADE 5
• shows
nonenhancement
of the right kidney.

• relatively small
amount of
perinephric or
intraperitoneal
hemorrhage.
IVU VS CT
• One-shot normal IVU

• Ten-minute
radiograph taken after
contrast
administration on a
patient with a stab
wound to the back

• normal kidneys and

ureters bilaterally.
IVU VS CT
• Kidney trauma. Grade
3 renal laceration with
normal one-shot
intravenous
pyelogram.

• CT scan shows renal

laceration and
perinephric
hematoma.
ANGIOGRAPHY

• initial diagnosis of trauma to the renal vasculature has

diminished with the advent of faster CT scanners.

• the trend toward nonoperative management of

trauma.
• angiography + transcatheter embolizationà the
standard of care for treating stable patients with
vascular injuries, such as traumatic pseudoaneurysms
and active arterial bleeding.
ANGIOGRAPHY
Active vascular contrast
extravasation.
Arterial phase Shows a
small pseudoaneurysm at
the lower pole.
• nephrographic phase
shows a small
pseudoaneurysm at the
lower pole.
• embolized by
using a coil.
BLADDER INJURY
AETIOLOGY

• Blunt trauma : 10% of pelvic fractures.

• Penetrating trauma :gunshots or stap wounds.
• Iatrogenic:-
• Post Operatif
• Idiopathic: due to presence of a previous scar.
CT, CYSTO, CT CYSTO

• A bladder injury, such as gross hematuria or pelvic ring fracture, are present à,
conventional cystography or CT cystography after initial CT.

• Cystography has a higher sensitivity for detecting bladder injuries.

 CT cystography is equal /better than
conventional cystography, if adequate
bladder distension can be achieved
with contrast material.

CT
CYSTOGRAPHY
CT cystography also provides the ability
to differentiate between
intraperitoneal, extraperitoneal, or
combined bladder rupture
 • Retrograde bladder distention (350 cc)
• Intravenous bolus injection and oral
administration of contrast material.
CT • Post drainage à decompressed à not
CYSTOGRAPHIC required.

TECHNIQUE • Removal of the Foley catheterà bladder

base lacerationsàunnecessary.
• Simple deflation of the balloon with
possible inadvertent removal of the
catheter would be detrimental à urethral
injury.
CLASSIFICATION OF
BLADDER INJURY
TYPE 1
CONTUSION

• Incomplete/partial tear of the bladder mucosa .

• Although hematuria àconventional and CT cystography are

normal.

• The most common bladder injury in multitrauma but is not in itself

considered to be a major bladder injury.
 TYPE 2
INTRAPERITONEAL RUPTURE

• 10%–20% of major bladder injuries à a direct blow to the

already distended bladder.

• intravesicular pressure à intraperitoneal rupture of

the bladder dome.

• Intraperitoneal contrast material around bowel loops,

between mesenteric folds, and in the paracolic gutters
TYPE 2
TYPE 2
inadequate distention Adequate distention
Retrograde bladder filling (-) Retrograde bladder filling (+)
TYPE 3
INTERSTITIAL INJURY

• Rare
• An intramural or partial-thickness laceration with intact
serosa.
• Intramural contrast material without extravasation
 • The most common type (80%–90% )
• Penetrating trauma.
TYPE 4 • Blunt traumaàdirect laceration by bone
fragments from a pelvic fracture.
EXTRAPERITONEAL
• Simple à perivesical space
RUPTURE
• Complex à extends beyond the
perivesical space
• May dissect into a variety of fascial
planes and spaces
TYPE 4
“molar tooth” appearance
TYPE 5
COMBINED RUPTURE

• The prevalence of combined bladder rupture is 5%–

12%à penetrating and blunt trauma

• Extravasation patterns that are typical for both types

of injury.

• Only one component of bladder injury was

demonstrated at cystography
 • Combined rupture in a 20-year-old man who sustained
multiple pelvic fractures in a motor vehicle accident
CASE REPORT
July 30
 CASE • Combined rupture in a 32-
year-old woman who
sustained multiple pelvic
REPORT fractures in a motor vehicle
accident (TYPE 5)
UNSTABLE
PELVIC
FRACTURE
14/2-2011
• External fixation
• Hematoma cavum retzius.
• Rupture bladder 1x1cmà debris
• Dome rupture à intraperitoneal
• Bladder mucosal hematoma
19/02/2011
• Peritonitis, ileal perforation, bladder rupture post repair
• Thick fluid with feces
• Gaster,duadenum, jejunum intact
• Perforation of the ileum
• Coecum,colon ascenden,transversum, descenden and
sigmoid intact
URETHRAL INJURY
ANATOMY
URETHRAL INJURY
• A common complication of pelvic trauma
( 24% of adults with pelvic fractures).

• 20% of patients with this type of injury have an associated

bladder laceration
STABLE FRACTURE UNSTABLE FRACTURE
 • Suspected urethral injury à
urethrography should be performed to
rule out such injury before a
transurethral catheter is inserted

• Blind insertion of a catheter

URETHROGRAPHY • Extent of a hemorrhage
• Introduce an infectious agent into a
previously sterile hematoma
• Extension of a partial tear into a
complete tear.
The American Association For Surgery Of Trauma
(AAST) Classification
Goldman Classification
TYPE 1

• Intact but stretched

posterior urethra following
blunt trauma

• Diastasis of the pubic

symphysis was diagnosed.
Figure 5B
TYPE 2 PARTIAL

• intact urogenital diaphragm following

blunt trauma

• Contrast material extravasation Above

the normal cone-shaped proximal
portion of the bulbous urethra.

• Contrast material flows through the

prostatic urethral lumen into the
bladder.

• Fracture of the left pubic ramus was

diagnosed.
TYPE 2 COMPLETE
• Posterior urethral rupture above the intact
urogenital diaphragm following blunt trauma

• A large amount of contrast material

extravasation without flow into the prostatic
urethra or bladder.

• Fracture of the right pubic ramus was

diagnosed..
TYPE 3
• Posterior urethral rupture extending through the
urogenital diaphragm to involve the bulbous
urethra following blunt trauma

• contrast material extravasation at the

membranous urethra (arrow).

• The contrast material extends below the

urogenital diaphragm and surrounds the proximal
bulbous urethra..
TYPE 4
• extraperitoneal periurethral contrast material
extravasation at the bladder neck (arrow).

• The bladder is pear shaped, indicative of

perivesical hematoma.

• Diastasis of the pubic symphysis was diagnosed

TYPE 4
• bladder base injury following blunt
trauma

• Shows extraperitoneal contrast

material extravasation that extends
from the elevated bladder base and
surrounds the proximal urethra.

• Fracture of the superior and inferior

pubic rami bilaterally was diagnosed.
TYPE 4 WOMAN
Traumatic rupture of the female urethra is rare.

Rupture of the urethra should be suspected when blood is present

at the external meatus or there is deep vaginal laceration (type IV
injury).

The urethra may be avulsed at or within 2 cm of the bladder neck

TYPE 4 WOMAN
• Bladder neck urethral injury (type IV) in a
woman.

• extraperitoneal contrast material extravasation

(arrow) that extends from the bladder neck to
the left underneath the balloon of a Foley
catheter.

• Cystogram obtained 2 minutes later shows

progressive extraperitoneal contrast material
extravasation.
TYPE 4
• Bladder neck urethral injury

• Delayed contrast material-

enhanced CT scan shows a
laceration of the anterior wall of
the urethra near the bladder neck
(arrowhead), with extraperitoneal
contrast material extravasation
that extends to the diastatic pubic
symphysis.

• Diastasis of the pubic symphysis

and fracture of the left pubic
ramus were diagnosed.
 • Caused by straddle injury and occur in the
bulbous urethra

• The bulbous urethra and corpus spongiosum are

TYPE V
compressed between the hard object and the
inferior aspect of the pubic bones à urethral
contusion with an intact urethra or partial or
complete rupture.

In general, a straddle urethral injury is not

associated with a bone injury.
TYPE V

• Anterior urethral injury following blunt

trauma

• complete disruption of the proximal

bulbous urethra with extensive venous
intravasation.
TIPE V
CASE REPORT

• Urethral rupture in a 22-year-old man who was injured in a fall from

scaffolding
CASE REPORT
• Scrotal hematoma
• Perineal hematoma
• Hematuria
US
normal testis with scrotal hematoma
RETROGRADE URETHROGRAPHY

• Scrotal opasity
• Intact pelvic bone
URETHROGRAPHY RETROGRADE Urethral
Rupture Pars bulbosa, contrast extravasation (type V)
A 64 yo, urethral trauma
SUMMARY
• Renal injury is the most common urologic trauma, in most
cases are associated with injuries to other major organs.

• Bladder and urethral injury should be suspected and excluded

in patients with pelvic fractures