Urologic & Renal Injury Assessment

• Initial urologic assessment involves gathering history from the patient or eyewitnesses, considering motor vehicle accidents or gunshot wounds

Physical Examination for Urologic Issues

• A pelvic fracture, blood at the urethral meatus, superior prostate displacement, flank hematoma or tenderness, and rib fracture are key indicators
• Perform a retrograde urethrogram if blood is present at the meatus or a pelvic fracture is suspected
• Conduct urinalysis, CT scan with IV contrast, or IV urogram (IVU)

Renal Injury Assessment

• Microscopic (> 5 RBCs) or gross hematuria can be present, but in 10-25% of cases, hematuria may be absent, especially with renal pedicle injuries
• Penetrating trauma, such as gunshot or stab wounds, often requires surgical exploration, and the absence of hematuria does not rule out renal injury
• Perform a CT scan with IV contrast pre-operatively
• Renal arteriography is necessary if non-function extravasation is suspected due to laceration or a large perirenal hematoma
• During surgery, an intraoperative single-shot IVU can confirm the function of the contralateral kidney if adequate imaging is lacking

Blunt Renal Trauma

• Blunt renal trauma can result from rapid deceleration, such as in motor vehicle accidents or falls
• Hematuria is typically present, necessitating a CT scan with IV contrast
• The presence of lumbar and lower rib fractures should raise suspicion

Classification & Management of Renal Injuries

• For hemodynamically unstable patients, use double-dose IVU; for stable patients, use CT with IV contrast
• Grade I-III injuries, and some higher grade injuries, are managed non-operatively with strict bed rest, ABX coverage, serial hematocrit readings, and monitoring of vital signs and imaging until gross hematuria resolves
• Renal pedicle injuries require immediate surgery for revascularization or nephrectomy

Urinary Extravasation

• Urinary extravasation, or urine accumulation in the peritoneal or retroperitoneal spaces, can be corrected by internal ureteral stent placement
• Late complications of conservative management include hypertension, abscess, delayed hemorrhage, hydronephrosis, and arteriovenous fistula

Ureteral Injury

• Ureteral injuries are typically the result of surgical mistakes like ligation or transection, or from gunshot wounds
• Hematuria is present in 90% of cases
• Diagnosis involves identifying obstruction or extravasation on contrast CT or IVU

Intraoperative Assessment & Management

• During surgery, if a ureteral injury is suspected, inject 5 mL of indigo carmine IV and inspect for bluish extravasation via cystoscopy
• Management includes immediate re-exploration and repair with watertight, tension-free anastomoses
• Options for lower ureteral injuries include anti-refluxing reimplantation, psoas hitch, and Boari bladder tube flap

Management for Ureteral Injuries

• Mid-ureteral injuries require primary ureteroureterostomy or transureteroureterostomy
• Upper ureteral injuries may need primary ureteroureterostomy, replacement with an ileal segment, autotransplantation into the pelvis, or nephrectomy

Bladder Injury Indicators

• Pelvic fractures (pubic rami) from blunt or penetrating trauma can cause extraperitoneal perforation or intraperitoneal rupture with a full bladder
• Hematuria is present in 100% of cases, with gross blood in 90%

Diagnosis and Action

• Diagnosis involves a distention cystogram with 300-400 mL of dilute contrast and post-drainage films
• A teardrop bladder deformity indicates a massive pelvic hematoma
• CT cystography is useful for assessing bladder integrity

Management of Bladder Injuries

• Penetrating injuries require surgical exploration, 5 mL of indigo carmine to confirm ureteral integrity, a suprapubic catheter, and possible penrose drainage
• Intraperitoneal bladder injuries: surgical exploration and suprapubic injury
• Extraperitoneal injuries: conservative treatment with a simple Foley catheter

Urethral Injury

• Urethral injuries are uncommon
• Posterior urethral injuries: pelvic fracture at the prostatomembranous junction

Posterior Urethral Injury findings

• Blood at the meatus and a high-riding prostate, with extraperitoneal extravasation seen above the urogenital diaphragm on retrograde urethrogram, indicates posterior urethral injury
• Management involves suprapubic urinary diversion via open cystostomy and possible endoscopic realignment
• Complications: stricture, impotence, and incontinence

Anterior Urethral Injury

• Anterior urethral injuries result from straddle-type trauma
• Bloody urethral discharge and a perineal bruise (butterfly hematoma) are indicative
• Extravasation below the urogenital diaphragm occurs

Next Steps

• Management: suprapubic drainage for 1-3 weeks
• Complication: stricture is most common

Penile Injuries

• Penile injuries are caused by penetrating trauma, gunshot wounds, stabs, strangulation, or blunt force
• Corpora cavernosa injuries can arise from blunt trauma
• If Buck’s fascia is intact, hematoma will be confined to the penis

When Buck's Fascia is Disrupted

• When Buck's fascia is disrupted, hematoma can spread under Colles' and Scarpa's fascia onto the perineum and abdominal wall
• Management involves removing penile skin distal to the injury, followed by a split-thickness skin graft

Surgical Exploration & Ruptured Corpora Cavernosa

• Penetrating penile injuries deep into Colles' fascia should be explored
• Ruptured corpora cavernosa require exploration with evacuation of clots, debridement, and repair of the tunica albuginea

Scrotal and Testicular Injuries

• Injuries can be penetrating or blunt
• Rule out testicular torsion or epididymitis

Burn Injury

• Burn injuries require careful monitoring
• Debridement of devitalized tissue and topical therapy with silver sulfadiazine are necessary
• Place a Foley or suprapubic catheter in extensively burned patients