Martinez_new_A4_book_04 16/03/2010 10:52 Page 62
Trauma Genital Trauma
Urinary Tract and Genital Trauma
Jorge López-Tello
1
and Luis Martínez-Piñeiro
2
1. Consultant Urologist; 2. Professor and Chairman, Urology Unit, Infanta Sofia Hospital, Madrid
Abstract
The management of urological trauma has changed in the past 10 years. Renal trauma is now managed more conservatively than it was
a few years ago. Selective renal embolisation for haemorrhage control is a reasonable alternative to laparotomy in selected patients.
Endovascular stenting of thrombosed renal arteries due to blunt traumatic renal artery dissection is a new conservative treatment
alternative. Delayed formal urethroplasty at three to six months after injury is the most commonly used approach in posterior urethral
injuries and is still the gold standard for treating posterior urethral distraction defects. Primary endoscopic realignment, which is usually
performed during the first 10 days after the injury, is an alternative treatment in selected patients. It may avoid formal reconstruction in
a small percentage of patients and may facilitate delayed formal reconstruction.
Keywords
Trauma, kidney, bladder, ureter, urethra, genital trauma, kidney trauma, bladder trauma, urethral trauma, ureteral trauma
Disclosure: The authors have no conflicts of interest to declare.
Received: 18 November 2009 Accepted: 18 January 2010
Correspondence: Luis Martínez-Piñeiro, Urology Section, Infanta Sofia Hospital, Paseo de Europa 34, 28702 San Sebastián de los Reyes, Madrid, Spain.
MARTINEZ-PINEIRO@telefonica.net
Renal Trauma In patients with penetrating trauma, if RI is clinically suspected, or
Renal injury (RI) occurs in approximately 1–5% of all traumas.
1
The when any degree of haematuria is present, renal evaluation should be
kidney is the most commonly injured genito-urinary and abdominal performed. The Association for the Surgery of Trauma (AAST) organ-
organ. Blunt trauma accounts for the largest percentage of renal injury severity scale for renal injuries
2
can be seen in Table 1. The role
injuries, while gunshot and stab wounds represent the most common of ultrasound is limited, but may be used in the serial evaluation of
causes of penetrating injuries, which tend to be more severe. stable renal injuries and as a screening test to identify patients
requiring radiological exploration.
3
Diagnosis
History and Physical Exam When patients go immediately to the operating room, intra-
Valuable information should be obtained about the type of trauma operative one-shot intravenous pyelography (IVP), after 10 minutes
(rapid deceleration, fall, etc.) or, in penetrating injuries, the type and of intravenous (IV) injection of contrast, can be helpful for decision-
calibre of the weapon used. Pre-existing renal abnormalities making in the critical time of urgent laparotomy, and documents the
(ureteropelvic junction obstruction, large cysts, lithiasis) make RI more presence of a functioning contralateral kidney. Standard IVP,
likely following trauma. Haematuria, flank pain, flank ecchymoses, magnetic resonance imaging (MRI) and radiographic scintigraphy
flank abrasions, fractured ribs and abdominal distension or mass may are no longer the studies of choice for the evaluation of renal
indicate possible renal involvement. trauma, but may be performed in centres where computed
tomography (CT) is not available. MRI may also be useful in patients
Laboratory Findings with iodine allergy.
Haematuria does not correlate with the degree of injury. Microscopic
haematuria (>5 red blood cells per high-power field) or gross CT is the gold standard method for the radiographic assessment of
haematuria are neither sensitive nor specific for differentiating minor stable patients with renal trauma,
4
as it defines the location of injuries
and major injuries. Interval haematocrit and the requirement for blood and pre-existing abnormalities, easily detects contusions and
transfusions is an indirect sign of the rate of blood loss and is crucial devitalised segments, visualises the entire retroperitoneum and
in the decision-making process. provides a view of the abdomen and pelvis.
5
A lack of contrast
enhancement of the kidney or a central parahiliar haematoma
Imaging suggest the possibility of pedicle injury. The presence of a large
Patients with blunt trauma and microscopic haematuria, but without haematoma medial to the kidney and displacing the renal vasculature
shock or a deceleration mechanism, have a low incidence of suggests a venous injury. If a very fast ‘spiral’ CT is performed,
significant renal injuries, and do not require imaging. delayed scans should be made to rule out urinary extravasation.
62 © TOUCH BRIEFINGS 2009
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