Eau 2020 - Urological Trauma

EAU Guidelines on
Urological Trauma
N.D. Kitrey (Chair), N. Djakovic, P. Hallscheidt, F.E. Kuehhas,
N. Lumen, E. Serafetinidis, D.M. Sharma
Guidelines Associates: Y. Abu-Ghanem, A. Sujenthiran,
M. Waterloos
EAU reading Presentation by

RTH-FAW
UROGENITAL TRAUMA
GUIDELINES
• Renal Trauma
• Ureteral Trauma
• Bladder Trauma
• Urethral Trauma
• Genital Trauma
RENAL TRAUMA
EPIDEMIOLOGY,
ETIOLOGY
Epidemiology :
- Present in to up 5% of all trauma cases
- Most common in young males and has an overall
population incidence of 4.9 per 100,000
Etiology
- Blunt
- Penetrating
AAST renal injury grading scale
EVALUATION
• Mechanism of injury
• Vital sign
• Physical examination
• Urinalysis, Hematocrit, Baseline creatinine
IMAGING
Indications
• Visible haematuria;
• Non-visible haematuria and one episode of
hypotension;
• A 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
• Establish the presence of the contralateral kidney
and demonstrate concurrent injuries to other
organs
• Ideally performed as a three-phase study:
1. The arterial phase assesses vascular injury and
presence of active extravasation of contrast;
2. The nephrographic phase optimally demonstrates
parenchymal contusions and lacerations;
3. the delayed phase imaging (5 minutes) identifies
collecting system/ureteric injury .
Ultrasonography (US)
• In the primary survey of a critically injured patient,
FAST is used to identify hemoperitoneum as cause
of haemorrhage and hypovolemia.
Intravenous pyelography (IVP)

• Only be performed when CT is not available
• One-shot intra-operative IVP can be used to
confirm the presence of a functioning contralateral
kidney in patients too unstable to have had pre-
operative imaging
Magnetic resonance imaging (MRI)
• Diagnostic accuracy of MRI in renal trauma is
similar to that of CT
• Impractical in acute trauma
Radionuclide scans
• It does not play a role in the immediate evaluation
• Follow-up scans can be used to identify areas of
scarring, functional loss or obstruction (long terms)
MANAGEMENT OF RENAL TRAUMA
Management of renal trauma
FOLLOW-UP
• Physical examination,
• Urinalysis,
• Diagnostic imaging,
• Blood pressure measurement, and
• Serum creatinine
COMPLICATIONS
• Early (≤ 1 month) : bleeding, infection, perinephric
abscess, sepsis, urinary fistula, hypertension,
urinary extravasation and urinoma
• Delayed : bleeding, hydronephrosis, calculus
formation, chronic pyelonephritis, hypertension,
arteriovenous fistulae (AVF), hydronephrosis and
pseudo-aneurysms
URETERAL
TRAUMA
INCIDENCE, EPIDEMIOLOGY,
AETIOLOGY
• Relatively rare
• Iatrogenic trauma is the most common cause of
ureteral injury (approximately 80%)
• Iatrogenic ureteral trauma can result from various
mechanisms: ligation or kinking with a suture,
crushing from a clamp, partial or complete
transection, thermal injury, or ischaemia from
devascularisation
• Gynaecological operations are the most common
cause of iatrogenic trauma
Incidence of ureteral injury in
various procedures
Procedure Percentage %
Gynaecological
Vaginal hysterectomy 0.02 – 0.5
Abdominal hysterectomy 0.03 – 2.0
Laparoscopic hysterectomy 0.2 – 6.0
Urogynaecological (anti-incontinence/prolapse) 1.7 – 3.0
Colorectal 0.15 – 10
Ureteroscopy
Mucosal abrasion 0.3 – 4.1
Ureteral perforation 0.2 – 2.0
Intussusception/avulsion 0 – 0.3
Radical prostatectomy
Open retropubic 0.05 – 1.6
Robot-assisted 0.05 – 0.4
DIAGNOSIS
Clinical diagnosis
• External ureteral trauma usually accompanies severe abdominal
and pelvic injuries.
• Penetrating trauma is usually associated with vascular and
intestinal injuries
• Blunt trauma is associated with damage to the pelvic bones and
lumbosacral spine injuries
• Haematuria is an unreliable and poor indicator of ureteral injury
• Iatrogenic injury may be noticed during the primary procedure
• Early recognition facilitates immediate repair and provides better
outcome
DIAGNOSIS
Radiological diagnosis
• 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
• In unclear cases, a retrograde or antegrade urography is
the optimum standard for confirmation
• Intravenous pyelography, especially one-shot IVP, is
unreliable in diagnosis, as it is negative in up to 60% of
patients
PREVENTION OF IATROGENIC
TRAUMA
• The use of prophylactic pre-operative ureteral stent
insertion assists in visualisation and palpation and is
used in complicated cases
MANAGEMENT
• Management of ureteral trauma depends on many factors
concerning the nature, severity and location of the injury.
• Immediate diagnosis of a ligation injury during an operation can
be managed by de-ligation and stent placement.
• Partial injuries can be repaired immediately with a stent or
urinary diversion by a nephrostomy tube
• Its insertion has to be weighed against potentially aggravating
the severity of the ureteral injury.
• Immediate repair of complete ureteral injury is usually
advisable.
• Injuries that are diagnosed late are usually managed first by a
nephrostomy tube or a stent
Management of ureteric
injuries
End-to-end Transuretero-ureterostomy
Uretero-calycostomy Boari
Psoas hitch Intestinal- interposition
Principles of surgical repair of ureteral
injury
BLADDER TRAUMA
Bladder trauma
Classification:
• intraperitoneal,
• Extraperitoneal (associated with pelvic fractures), and
• Combined intra-extraperitoneal
Categorised by aetiology:
• non-iatrogenic (blunt and penetrating)
• iatrogenic (external and internal)
• . Intraperitoneal injury is caused by a sudden rise in intravesical
pressure of a distended bladder, secondary to a blow to the
pelvis or lower abdomen.
Diagnostic evaluation
• Absolute indications: visible haematuria and a pelvic
fracture or non-visible haematuria combined with
high-risk pelvic fracture or posterior urethral injury.
• Relatives indications:
• inability to void or inadequate urine output;
• abdominal tenderness or distension due to urinary
ascites, or signs of urinary ascites in abdominal imaging;
• uraemia and elevated creatinine level due to intra-
peritoneal re-absorption;
• entry/exit wounds at lower abdomen, perineum or
buttocks in penetrating injuries.
Intra-operative signs: extravasation of urine, visible
laceration, visible bladder catheter, and blood and/or
gas in the urine bag during laparoscopy.
Internal bladder injury: fatty tissue, dark space, or
bowel.
• Cystography:
• Intraperitoneal: free contrast medium in the abdomen
outlining bowel loops or abdominal viscera.
• Extraperitoneal: flame-shaped areas of contrast
extravasation in the perivesical soft tissues.
• Cystoscopy (intra-operative): visualise and localise
the lesion
Management
Urethral Trauma
• Anterior urethra are caused by straddle injuries,
trauma during sexual intercourse, penetrating
trauma and from iatrogenic trauma e.g. endoscopic
instruments, catheterisation.
• Pelvic fractures are the predominant cause of male
posterior and female urethral injury.
Diagnostic Evaluation
• Blood at the external urethral meatus
• Inability to void
• pain on urination
• high-riding prostate
• Penile and scrotal swelling and haematoma
• Retrograde urethrography is the standard in the
early evaluation
Urethrogram demonstrating
Urethrogram demonstrating
partial urethral disruption
complete urethral disruption
Management
Management
Genital Trauma
DIAGNOSTIC EVALUATION
Patient history and physical examination
• In genital trauma, a urinalysis should be performed.
The presence of visible haematuria requires a
retrograde urethrogram in males.
• In females, flexible or rigid cystoscopy is
recommended to exclude urethral and bladder
injury
• In women with genital injuries and blood at the
vaginal introitus, further gynaecological
investigation is needed
Evaluation and Management
Cont.
TERIMA KASIH

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EAU Guidelines on

EAU reading Presentation by

Intravenous pyelography (IVP)

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