- The initial resuscitation process can be divided into three phases \200\224the primary surv ey, the secondary survey, the de \201 nitive survey. Primary survey ABC: assess the patient \200\231s Airway, Breathing, and Circulation. Airway and Breathing - - Establish a secure airway. Ventilate by oxygen mask or endotracheal intubation and mechanic al ventilation. Immobilize the cervical spine. Circulation Assess circulatory function by pulse rate and BP. The commonest cause of hypotension in the polytraumatized patient is hypovolaemia secondary to hemorrhage. With hypovolaemic shock, an immediate bolus of intravenous isotonic crystal loid solution should be given and the patient \200\231s response (pulse rate, BP) is assess ed. Radiological imaging Determined by local facilities. Increasingly, in the severely traumati zed pa- tient, CT of chest, abdomen, and pelvis is used to identify signi \201 cant chest, abdominal, and pelvic injuries. If not available, arrange supine chest, abdo- men, and pel vic X-rays to identify the presence of rib and pelvic fractures and to identify the presenc e of signi \201 cant quantities of blood in the chest, abdomen, and pelvis and in patients with persistent hypotension from pre- sumed bleeding, search for occult hemorrhage using a diagnostic perito- neal lavage or focused abdominal USS. Hypovolaemic shock is not always associated with hypotension. In young patients, compensato ry mechanisms, e.g. rapid vasoconstriction can compensate for as much as a 35% volume loss without signi \201 cant decreases in BP. Remember non-hypovolaemic causes of hypotension: Tension pneumothorax. Cardiac tamponade. M yocardial infarction. Neurogenic ( - - SCI). INITIAL RESUSCITATION OF THE TRAUMATIZED PATIENT 507 Urinalysis Routinely performed in every trauma patient because it provides valuable informa tion regarding the likelihood of injuries to the upper and lower urinary tract. The absence of haematuria, however, does not exclude a urinary tract injury (e.g. haematuria may be ab sent in acceleration/deceler- ation renal injuries (see b p. 508)). As life-threatening injuries are found during the primary survey, resus- citation efforts a re initiated concurrently (e.g. chest drain for pneumotho- rax). The decision to transfer a patient from the emergency room to either the operating room or angiography suite is made during the primary survey. Secondary survey Performed after completion of the primary survey. Take a completehis- tory and perform a physical examination from head to toe. Arrange selec- tive skeletal X-rays a ccording to physical \201 ndings. De \201 nitive survey During this phase, focus attention on identifying speci \201 c orga n injuries using clinical and radiographic means. Genitourinary injuries are usually recogn ized during the de \201 nitive survey. During all phases of the initial resuscitation, assess vital signs (BP, respi- ratory rate, blood gasses, urinary output, and body temperature) continu- ally. Vascular pressure monit oring, using central venous and pulmonary arterial catheters, can be performed selectively. Frequent re-evaluation should be performed to detect changes in the patient \200\231s cond ition and the appropriate actions taken. CHAPTER 11 Trauma to the urinary tract 508 Renal trauma: classi \201 cation, mechanism, grading Classi \201 cation Two categories \200\224blunt and penetrating. See Table 11.1. Proportion of all renal injuries that are bl unt \200\224Europe 97%, United States 90%, South Africa 25 \200\22385%. Proportion depends on whether urban or non-urban community. This classi \201 cation is useful because it predicts the likely need for surgical explora tion to control bleeding. Experience from large series shows that 95% of blunt injuries can be managed conservatively whereas 50% of stab injuries and 75% of gunshot wounds require e xploration. Blunt injures - - - Direct blow to the kidney. Rapid acceleration or rapid deceleration. A combination of the a bove. Rapid deceleration frequently causes renal pedicle injuries (renal artery and vein tears or thrombosis, PUJ disruption) because the renal pedicle is the site of attachment of the kid ney to other \201 xed retroperitoneal structures. Most common cause \200\224motor vehicle accidents (e.g. pedestrian hit by a car, direct blo w combined with rapid acceleration and then deceleration). Seemingly trivial injuries (e.g. fall from a ladder), direct falls onto the \202 ank, or sporting injuries can lead to si gni \201 cant renal injuries. Penetrating injuries Stab or gunshot injuries to the \202 ank, lower chest, and anterior abdominal area may in \202 ict renal damage. Fifty percent of patients with penetrating tr auma and haematuria have grade III, IV, or V renal injuries. Penetrating injuries anterior to the anterior axillary line are more likely to injure the renal vessels and renal pelvis, compared with injuries posterior to this line where less serious parenchymal injuries are more likely. Thus, renal inju- ries from stab wounds to the \202 ank (i.e. posterior to t he anterior axillary line) can often be managed non-operatively. Wound pro \201 le of a low-velocity gunshot wound is similar to that of a stab wound. High -velocity gunshot wounds (>350m/s) cause greater tissue damage due to stretching of surroun ding tissues ( \200\230temporary cavity \200\231). Mechanism The kidneys are retroperitoneal structures surrounded by perirenal fat, the verte bral column and spinal muscles, the lower ribs, and abdominal contents. They are, therefore , relatively protected from injury and a con- siderable degree of force is usually required to injure them (only 1.5 \200\2233% of trauma patients have renal injuries). Associated in juries are, therefore, common (e.g. spleen, liver, mesentery of bowel). Renal injuries may not initially be obvious, hidden as they are by other structures. To con \201 rm or exclud e a renal injury, imaging studies are required. In children, there is proportionately less perirenal fat to cushion the kidneys against injury and thus, renal injuries occur with les ser degrees of trauma. RENAL TRAUMA: CLASSIFICATION, MECHANISM, GRADING 509 Staging of the renal injury Using CT, renal injuries can be staged according to the America nAssociation for the Surgery of Trauma (AAST) Organ Injury Severity Scale. Higher inju- ry severity scales are associated with poorer outcomes. Grade I Contusion (normal CT) or subca psular haematoma with no parenchymal laceration. Grade II <1cm deep parenchymal laceration of cortex, no extravasa- tion of urine (i.e. collecting system intact). Grade III >1cm deep parenchymal laceration of cortex, no extravasa- tion of urine (i.e. collecting system intact). Grade IV Parenchymal laceration, involving cortex, medulla and collect- ing system OR renal artery or renal vein injury with contained hemorrhage. Grade V Completely shattered kidney OR avulsion of renal hilum. Pediatric renal injuries The kidneys are said to be more prone to injury in children becaus e of the relatively greater size of the kidneys in children, the smaller protective muscle mass and cushion of perirenal fat, and the more pliable rib cage. CHAPTER 11 Trauma to the urinary tract 510 Table 11.1 Summary of mechanisms, causes, grading, and treatment of renal disease Mechanisms and cause Blunt: direct blow or acceleration/deceleration (RTAs, falls from a height, fall onto \202 ank) Penetrating: knives, gunshots, iatrogenic (e.g. PCNL) Imaging and grading CT: accurate, rapid, images other intra-abdominal struc-tures Staging: AAST Organ Injury Severity Scale: I: contusion or subcapsular haematoma II: <1cm laceration without urinary extravasation III: >1cm laceration without urinary extravasation IV: laceration into collecting system, i.e. urinary extravasa-tion V: shattered kidney or avulsion of renal pedicle Treatment Conservative: 95% of blunt injuries, 50% of stab inju-ries, 25% of gunshot wounds can be ma naged non-operatively (cross-match, bed rest, observation) Exploration if: Persistent bleeding (persistent tachycardia and/or hy-potension not responding to appropria te \202 uid and blood replacement) Expanding perirenal haematuria Pulsatile perirenal haematoma See also: Santucci RA, Wessells H, Bartsch G, et al. (2004) Consensus on genitourinary trau ma. Evaluation and management of renal injuries: consensus statement of the renal trauma su bcommittee. Br J Urol Int 93:937 \200\22354. This page intentionally left blank CHAPTER 11 Trauma to the urinary tract 512 Renal trauma: clinical and radiological assessment The haemodynamically stable patient Hist ory: nature of trauma (blunt, penetrating) Examination: pulse rate, systolic BP, respirator y rate, location of entry and exit wounds, \202 ank bruising, rib fractures. The lowest r ecorded systolic BP is used to determine need for renal imaging. Urinalysis: crucial for de termining likelihood of renal injury and, therefore, of the need for radiological tests. Haematuria (de \201 ned as >5 erythrocytes per high powered \201 eld or dipstick-positiv e) suggests the possibility of a renal injury; however, the amount of haematuria does not c orrelate consistently with the degree of renal injury. Do FBC and serum chemistry pro \201 le. Indications for renal imaging - Macroscopic haematuria. - Penetrating chest and abdominal w ounds (knives, bullets). - Microscopic (>5 RBCs per high powered \201 eld) or dipstick ha ematuria in a hypotensive patient (systolic BP <90mmHg recorded at any time since the injur y).1 A history of a rapid acceleration or deceleration (e.g. fall from a height, high speed motor vehicle accident). Falls from even a low height can cause serious renal injury in th e absence of shock (systolic BP <90mmHg) and of haematuria (PUJ disruption prevents blood r eaching the bladder). Any child with microscopic or dipstick haematuria who has sustained t rauma. Adult patients with a history of blunt trauma and microscopic or dipstick haematuria need n ot have their kidneys imaged as long as there is no history of acceleration/deceleration an d no shock since the chances of a signi \201 cant injury being found are <0.2%. Degree of haematuria vs severity of injury While signi \201 cant renal injury is more like ly with macroscopic haematuria, in some cases of severe renal injury, haematuria may be abs ent. Thus, the relationship between the presence, absence and degree of haematuria and the severity of trauma is not absolute. Broadly speaking, in blunt trauma, macroscopic haematur ia predicts the likelihood of signi \201 cant renal injury (Table 11.2). Conversely, in pe netrating trauma, haematuria may be absent in severe renal injury (renal vascular injury, P UJ, or ureter avulsion). RENAL TRAUMA: CLINICAL AND RADIOLOGICAL ASSESSMENT 513 Table 11.2 Blunt trauma in adults: chance of signi \201 cant renal injury vs degree of hae maturia and systolic BP (SBP) Degree of haematuria; SBP (mmHg) Signi \201 cant renal injury (%) Microhaematuria;* >90 0.2 Macroscopic haematuria; >90 10 Macroscopic haematuria; <90 10 Dipstick or microscopic haematuria. The haemodynamically unstable patient Haemodynamic instability may preclude standard imagin g such as CT, the patient having to be taken to the operating theater immediately to contro l the bleeding. In this situation, an on-table IVU (Box 11.1) is indicated if: - - A retroperitoneal haematoma is found and/or A renal injury is found which is likely to requ ire nephrectomy. CHAPTER 11 Trauma to the urinary tract 514 Box 11.1 What imaging study? The IVU has been replaced by contrast-enhanced CT scan as the imaging study of choice in patients with suspected renal trauma. Compared with IVU, it prov ides clearer de \201 nition of the injury, allowing injuries to the parenchyma and collect ing system to be more accurately graded and, therefore, deter- mines subsequent management. An arterial-venous phase scan is done within minutes of contrast injection, followed by a repeat scan 10 \200\22320min after con- trast administration to allow time for contrast to reach collecting system. While ultrasound can establish the presence of two kidneys and identify blood \202 ow in the renal vessels (power Doppler), it cannot accurately identify parenchymal tears, collect ing system injuries, or extravasation of urine until a later stage when a urine collection has had time to accumulate. Imaging is designed to: Grade injury. Document presence and function of contralateral kidne y. Detect associated injuries. Detect pre-existing renal pathology in affected kidney. - - On contrast enhanced CT look for: - Depth of parenchymal laceration. - Parenchymal enhancem ent (absence of enhancement suggests renal artery injury). Presence of urine extravasation (medial extravasation of contrast suggests disruption of PUJ or renal pelvis). Presence, si ze, and position of retroperitoneal haematoma (haematoma medial to the kidney suggests a va scular injury). Presence of injuries to adjacent organs (bowel, spleen, liver, pancreas, et c). Presence of a normal contralateral kidney. On-table IVU When, because of shock and need for immediate laparotomy, a patient is transfe rred immediately to the operating theater without having hada CT scan and a retroperitoneal haematoma is found, a single shot abdom- inal X-ray, taken 10min after contrast administra tion (2mL/kg of contrast), can establish the presence/absence of a renal injury and the pre sence of a normally functioning contralateral kidney where the ipsilateral kidney injury is likely to necessitate a nephrectomy. Remember, in young adults and children, hypotension is a late manifestation of hypovolaemia : blood pressure is maintained until there has been substantial blood loss. This page intentionally left blank CHAPTER 11 Trauma to the urinary tract 516 Renal trauma: treatment Conservative (non-operative) management Most blunt (95%) and many p enetrating renal injuries (50% of stab injuries and 25% of gunshot wounds) can be managed n on-operatively. Dipstick or microscopic haematuria: if systolic BP since injury has always been >90mmHg and no history of acceleration or deceleration, imaging and admission is not required. Macroscopic haematuria: in a cardiovascularly stable patient, having staged the injury with CT, admit for bed rest (no hard and fast rules as to dura- tion) and observation until the macroscopic haematuria, if present, resolves (cross-match in case BP drops); give antibiot ics if urinary extravasation. High-grade (IV and V) injuries: can be managed non-operatively if they are cardiovascularly stable. However, grade IV and, especially, grade V injuries often require nephrectomy to c ontrol bleeding (grade V injuries function poorly if repaired). Surgical exploration Is indicated (whether blunt or penetrating injury) if: - The patient develops shock which does not respond to resuscitation with \202 uids and/or blood transfusion. The hemoglobin decreases (there are no strict de \201 nitions of what r epresents a \200\230signi \201 cant \200\231 fall in hemoglobin). There is urinary extrav asation and associated bowel or pancreatic injury. Expanding perirenal haematoma (again the patient will show signs of continued bleeding). Pulsatile perirenal haematoma. An expanding and/or pulsatile perirenal haematoma suggests a renal pedi- cle avulsion. Haem aturia is absent in 20%. Technique of renal exploration Midline incision allows: - Exposure of renal pedicle, so allowing early control of the renal artery and vein. Inspecti on for injury to other organs. Lift the small bowel upwards to allow access to the retroperitoneum. Incise the peritoneum over the aorta, above the inferior mesenteric ar- tery. A large peri-renal haematoma may ob scure the correct site for this incision. If this is the case, look for the inferior mesent eric vein and make your incision medial to this. Once on the aorta, the inferior vena cava may be exposed, then the renal veins and the renal arteries. Pass slings around all of thes e vessels. Expose the kidney by lifting the colon offof the retroperitoneum. Bleeding may b e reduced by applying pressure to the vessels via the slings. Control bleeding vessels with in the kidney with 4/0 vicryl or monocryl sutures. Close any defects in the collecting syst em with 4/0 vicryl. If your sutures cut out, place a strip of Surgicel over the site of ble eding, place your sutures through the capsule on either side RENAL TRAUMA: TREATMENT 517 of this, and tie them over the Surgicel. This will stop them from cutting through the friab le renal parenchyma. Finding a non-expanding, non-pulsatile retroperitoneal haematoma at laparotomy The \201 n ding of an expanding and/or pulsatile retroperitoneal haematoma at laparotomy will often in dicate a renal pedicle injury (avulsion or lacera- tion), and nephrectomy may be required t o stop further hemorrhage. Controversy surrounds the correct management of the \201 nding at lap- arotomy of a non-e xpanding, non-pulsatile retroperitoneal haematoma. Most can be left alone. Remember, explor ation increases the chances of loss of the kidney (because of bleeding which can becontroll ed only by nephrectomy). The decision to explore is based on whether pre-opera- tive or on- table imaging has been done and is normal or abnormal: Pre-operative or intra-operative imaging Action Normal Leave the haematoma alone Abnormal; contralateral kidney normal Explore and repair renal injury Abnormal; abnormal or absent contralateral kidney Leave the haematoma alone* None Explore and repair renal injury Exploration increases the chances of loss of the kidney (because of bleeding that can be co n- trolled only by nephrectomy), which is a disaster if the contralateral kidney is absent or damaged. Urinary extravasation Not in itself necessarily an indication for exploration. Almost 80 \200\22390% of these injuries will heal spontaneously. The threshold for operative repair i s lower with associated bowel or pancreatic injury \200\224bowel contents mix- ing with uri ne is a recipe for overwhelming sepsis. In these situations, the renal repair should be wel l drained and omentum interposed between the kidney and bowel or pancreas. If there is substantial contrast extravasation, consider placing a JJ stent. Repeat renal i maging if the patient develops a prolonged ileus or a fever since these signs may indicate the development of a urinoma which can be drained percutaneously. Renal exploration is requ ired for a persistent leak. Devitalized segments Exploration is usually not required for patients with devitalized segm ents of kidney and with urinary extravasation.1 Complications of renal injury2 \200\2234 Early - Delayed bleeding: 1.5% of surgically treated patients, 4% of surgically treated penetrating injuries, 1 \200\2236% of pediatric blunt injuries managed non-operatively, 20% of conserv atively managed stab injuries. 75%require surgery and of these, 60% require nephrectomy. CHAPTER 11 Trauma to the urinary tract 518 Urinary extravasation and urinoma formation: penetrating injury 10 \200\22325%. If low volu me and non-infected, often heal spontaneously; large volume \200\224consider a trial of JJ stenting with renal repair if extravasation persists. Abscess formation: Treat by percutane ous drainage. Renal arteriovenous \201 stulas: biopsy, i.e. iatrogenic. Often small and h eal spontaneously, but may manifest with retroperitoneal bleeding; collecting system bleedi ng (heavy haematuria); microscopic haematuria; abdominal bruit; hypertension; tachycardia; high output heart failure. Diagnosis is con \201 rmed by selective renal arteriography. Tr eat by arterial embolization (treatment of choice); partial nephrectomy; complete nephrecto my. blunt injury 2 \200\22320%; \202 ank pain, fever, ileus. CT or USS is diagnostic. commonest cause is percutaneous renal Late - - Decreased renal function. Hypertension. Hypertension and renal injury Excess renin excretion occurs following renal ischaemia from renal artery injury or thrombosis or renal compression by haematoma or \201 brosis (so- c alled \200\230Page \200\231 kidney). This can lead to hypertension months or years after r enal injury. The exact incidence of post-traumatic hypertension is uncer- tain. It may occu r in <1% of individuals. Iatrogenic renal injury: renal hemorrhage after percutaneous nephrolithotomy (PCNL) Signi \201 cant renal injuries can occur during PCNL for kidney stones. This is the surgical equi valent of a stab wound and serious hemorrhage results in 1% of cases.5 Bleeding during or after a PCNL can occur from vessels in the neph- rostomy track itself, f rom an arteriovenous \201 stula, or from a pseudoaneu- rysm which has ruptured. Track ble eding will usually tamponade around a large-bore nephrostomy tube. Traditionally, persisten t bleeding through the nephrostomy tube is managed by clamping the nephrostomy tube and wai ting for the clot to tamponade the bleeding. While this may control bleeding in some cases, in others, a rising or persistently elevated pulse rate (with later hypotension) indicates the possibility of persistent bleed- ing and is an indication for renal arteriography and embolization of the arteriovenous \201 stula or pseudoaneurysm (Figs 11.1 and 11.2). Fail ure to stop the bleeding by this technique is an indication for renal exploration. Arteriov enous \201 stulae can sometimes occur following open renal sur- gery for stones or tumors and arteriography with embolization again can be used to stop the bleeding in these cases. However, the bleeding usually occurs over a longer time course (days or even weeks) rather than as an acute hemorrhage causing shock. 1 Toutouzas KG (2002) Non-operative management of blunt renal trauma: a prospective study. Am Surg 68:1097 \200\223103. 2 McAninch JW, Carroll PR, Klosterman PW, et al. (1991) Renal reconstruction after injury. J Urol 145:932. 3 Carroll PR, McAninch JW. (1985) Operative indications in penetrating renal trauma. J Trau ma 25:587. RENAL TRAUMA: TREATMENT 519 Fig. 11.1 Renal arteriography after PCNL where severe bleeding was encountered. An arteriov enous \201 stula was found and embolized. Fig. 11.2 Post-embolization of arteriovenous \201 stula. Note the embolization coils in t he lower pole. 4 Bernath AS, Shutte H, Fernandez RRD, et al. (1983) Stab wounds of the kidney: conservativ e management in \202 ank penetration. J Urol 129:468. 5 Martin X (2000) Severe bleeding after nephrolithotomy: results of hyperselective emboliza tion. Eur Urol 37:136 \200\2239. CHAPTER 11 Trauma to the urinary tract 520 Ureteric injuries: mechanisms and diagnosis Types, causes, and mechanisms - External: height); penetrating (knife or gunshot wounds). Internal trauma e.g. hysterectomy , colectomy, AAA repair; ureteroscopy. The ureter may be divided, ligated, or angulated by a suture; a segment excised or damaged by diathermy. rare \200\224blunt (e.g. high-speed road traf \201 c accidents, fall from a (= iatrogenic): during pelvic or abdominal surgery, External injury: diagnosis Based on a high index of suspicion for the possibility of ureter ic injury in the types of scenarios (see Types, causes, and mechanisms). Imaging studies: I VU or CT can be used to determine the presence of a ureteric injury. If doubt remains regar ding the integrity of the ureters, retrograde ureterography should be done. Internal (iatrogenic) injury: diagnosis The injury may be suspected at the time of surgery, but injury may not become apparent until some days or weeks post-operatively. Intraoperative diagnosis For ureteric contusions and perforations seen at the time of urete roscopy, insert a JJ stent. During abdominal or pelvic surgery, \201 rst optimize expo- s ure of the suspected injury site by packing bowel out of the way, control- ling bleeding, a nd ensuring the theater lights are appropriately positioned. Examine both ureters (bilatera l injuries can occur). Direct inspection of the ureter A good way of inspecting the ureter for injury, but require s exposure of a considerable length of ureter to establish that it has not been injured. Lo wer ureteric exposure is more dif \201 cult than upper ureteric. Extravasation after injection of methylene blue into the ureter Look for leakage of dye fro m a more distant section of ureter. On-table IVU Technically dif \201 cult; does not always demonstrate the presence or site o f injury. On-table retrograde ureterography Via an incision made in the bladder or via a cystoscope. A very accurate method of establishing the presence or absence of a ureteric injury (see Fi g. 11.3). Both ureters can easily be examined. Post-operative diagnosis The diagnosis is usually apparent in the \201 rst few days follo wing surgery (Box 11.2), but it may be delayed by weeks, months, or years (presen- tation: \202 ank pain, post-hysterectomy incontinence \200\224a continuous leak of urine suggests a ureterovaginal \201 stula). URETERIC INJURIES: MECHANISMS AND DIAGNOSIS 521 Fig. 11.3 A normal retrograde ureterogram. Box 11.2 Symptoms and signs of ureteric injury May include: - - - An ileus (due to urine within the peritoneal cavity). Prolonged post-operative fever or ove rt urinary sepsis. Persistent drainage of \202 uid from drains, the abdominal wound, or t he vagina. Send this for creatinine estimation. Creatinine level higher than that of serum = urine (creatinine level will be at least 300 mol/L). Flank pain if the ureter has been l igated. Abdominal mass, representing a urinoma (a collection of urine). Vague abdominal pai n. The pathology report on the organ that has been removed may note the presence of a segme nt of ureter! - - Investigation: IVU or retrograde ureterogram. Ultrasonography may demonstrate hydronephrosi s, but hydronephrosis may be absent when urine is leaking from a transected ureter into the retroperitoneum or peri- toneal cavity. The IVU usually shows an obstructed ureter or occa sionally, a contrast leak from the site of injury. CHAPTER 11 Trauma to the urinary tract 522 Ureteric injuries: management When to repair the ureteric injury Generally, the best time t o repair the ureter is as soon as the injury has been diagnosed. Delay de \201 nitive ureteric repair when: The patient is unable to tolerate a prolonged p rocedure under general anesthetic. There is evidence of active infection at the site of pro posed ureteric repair (infected urinoma). A percutaneous nephrostomy should be placed, the infection drained radiologically (percutan eous drain), intravenous antibiotics given, and ureteric repair delayed until the patient i s apyrexial. Traditional teaching held that surgical repair should be delayed when the injury was diagno sed between roughly days 7 and 14 after ureteric injury, the time when maximal oedema and i n \202 ammation at the site of repair was believed to occur. However, favorable outcomes h ave been demonstrated after early repair and the time of the original injury is nowa- days seen as a less important determinant of time of de \201 nitive repair.1 De \201 nitive treatment of ureteric injuries The options depend on: - - - Whether the injury is recognized immediately. Level of injury. Other associated problems. The options are: JJ- stenting for 3 \200\2236 weeks (e.g. ligature injury recognized immedi ately). - - Primary closure of partial transection of the ureter. Direct ureter to ureter anastomosis ( primary uretero- ureterostomy) \200\224if the defect between the ends of the ureter is of a length where a tension-free anastomosis is possible. Reimplantation of the ureter into the bladder (uretero- neocystostomy), either using a psoas hitch or a Boari \202 ap (see Fig s. 11.4 and 11.5). Transuretero-ureterostomy (see Fig. 11.6). Autotransplantation of the ki dney into the pelvis \200\224where the segment of damaged ureter is very long. Replacement of the ureter with ileum \200\224where the segment of damaged ureter is very long. Permanen t cutaneous ureterostomy \200\224where the patient \200\231s life expectancy is very limite d. Nephrectomy \200\224traditionally advocated for ureteric injury during vascular graft pr ocedures (e.g. aortobifemoral graft for AAA), but the trend is towards ureteric repair and renal preservation, reserving nephrectomy only where a urine leak develops post-operatively (continuing drainage of urine from the drain placed at the site of ureteric anastomosis).2 URETERIC INJURIES: MANAGEMENT 523 (a) Ureter Psoas muscle and tendon Oblique cystotomy Bladder (b) Cut ureteral end Opened bladder wall (c) Fig. 11.4 A psoas hitch. (Reproduced from Reynard, J, Mark, S. et al, Urological Surgery. O xford University Press, with permission from OUP.) CHAPTER 11 Trauma to the urinary tract 524 (b) (a) (c) (d) Fig. 11.5 A Boari \202 ap. (Reproduced from Reynard, J, Mark, S. et al, Urological Surger y. Oxford University Press, with permission from OUP.) JJ stenting For some injuries, JJ stenting may be adequate for de \201 nitive treatment, p articularly where the injury does not involve the entire circumference of the ureter and co ntinuity is, therefore, maintained across the region of the ureteric injury. In situations where a ligature has been applied around the ureter and this has been immediately recognize d such that viability of the ureter has probably not been compromised, remove the ligature and place a JJ stent (cystoscopically if this is feasible or, if not, by opening the URETERIC INJURIES: MANAGEMENT 525 Ureter Stent Ureter Ureter Ureter Fig. 11.6 Transuretero-ureterostomy. (Reproduced from Reynard, J, Mark, S. et al, Urologica l Surgery. Oxford University Press, with permission from OUP.) bladder). If there has been a delay in recognition of a ligature injury to the ureter, it i s probably safer to remove the affected segment of ureter and perform a uretero-ureterostom y. Generally speaking, the stent is main- tained in position for somewhere between 3 and 6 weeks (no hard and fast rules). At the time of stent removal, perform a retrograde uretero- gram to con \201 rm that there is no persistent leakage of contrast from the original sit e of injury and to see if there is evidence of ureteric stricturing. Factors other than the level of injury are important in determining the type of repair. Blast injuries characteri stically cause considerable \200\230collat- eral \200\231 damage to the ureter and surroun ding tissues and this may not be apparent at the time of surgery. Delayed necrosis can occu r in such appar- ently normal-looking ureters. General principles of ureteric repair - The ends of the ureter should be debrided so that the edges to be anastomosed are bleeding freely. The anastomosis should be tension-free. For complete transection, the ends of the u reter should be spatulated to allow a wide anastomosis to be done. A stent should be placed across the repair. Mucosa to mucosal anastomosis should be done to achieve a watertight cl osure. Use 4/0 absorbable suture material. A drain should be placed around the site of anas tomosis. 1 Blandy JP, Badenoch DF, Fowler CG, Jenkins BJ, Thomas NW (1991) Early repair of iatrogeni c injury to the ureter and bladder after gynecological surgery. J Urol 146:761 \200\2235. 2 McAninch JW (2002) In: Walsh PC, Retik AB, Vaughan ED, Wein AJ (eds) Campbell \200\231s U rology, 8th edn. Philadelphia: WB Saunders pp. 3703 \200\22314. CHAPTER 11 Trauma to the urinary tract 526 Pelvic fractures: bladder and ureteric injuries Pelvic fractures are usually due to run-ove r or crush injuries where mas- sive force is applied to the pelvis. Associated head, chest, intra-abdominal (spleen, liver, mesentery of bowel), pelvic (bladder, urethra, vagina, rec - tum), and genital injuries are common and these injuries and the massive blood loss from torn pelvic veins and arteries account for the substantial (20%) mortality after pelvic fra cture. Initial assessment Pelvic fractures are often occult. Screen run-over or crush victims with a pelvic X-ray. Assess: - - Vital signs (pulse rate, systolic Neurovascular integrity of lower limb (lumbosacral plexus , peripheral nerves, and major vessels may be damaged). Examine for head, chest, abdominal, and perineal injuries. Determine stability/instability of the fracture from pelvic X-rays. BP). Is the fracture stable or unstable? See Box 11.3. Abdominal and pelvic imaging in pelvic fracture - Abdominal/pelvic CT: establishes presence/absence of associated pelvic (rectum, bladder) an d abdominal organ injury (liver, bowel, spleen). Retrograde urethrogram: perform retrograde urethrography only when blood is present at the meatus; others do this in all pelvic fract ure patients where the pubic rami have been disrupted. If the urethra is intact, a retrogra de cystogram is done to assess theintegrity of the bladder. to detect urethral injury. Some hospitals PELVIC FRACTURES: BLADDER AND URETERIC INJURIES 527 Box 11.3 Is the fracture stable or unstable? Stable = the fracture can withstand normal phy siologic forces. Unstable = the fracture cannot withstand normal physiologic forces. Instability suggests a greater degree of trauma to the pelvis and increases the likelihood of serious associated injuries. In addition, \201 xation of an unstable fracture reduces blood loss, mortality, hospital stay, leg length discrepancy, and long-term disability; mak es nursing care easier; and reduces analgesic consumption. Stability can be de \201 ned ac cording to the Tile classi \201 cation system of pelvic ring fractures (Table 11.3). Of unstable pelvic fractures, 70% are B2 and B3, 10 \200\22320% are open book type (B1), and 10 \200\22320% are type C. - Open book pelvic fracture (B1): compressio n. A dramatic rise in pelvic volume stretches vessels, nerves, and organs (e.g. bladder) (F igs. 11.7 and 11.8). Closed book pelvic fracture (B2 or B3): compression force to the pelvi s. The pubic rami fracture and overlap and the ilium and sacral wings may be fractured. Ner ves and vessels are not stretched, but the urethra is more likely to be damaged by scissors like action of overlapping pubic rami. Vertically unstable pelvic fracture (C): damaged by stretching. caused by anteroposterior caused by a lateral vessels and nerves can be Radiological determination of stability Based on inlet (for anteroposterior displacement) a nd outlet views (for vertical displacement) of the pelvis, the X-ray beam being angled acco rd- ingly. CT provides better de \201 nition of sacral, sacroiliac, and acetabular fractur es and dislocations. Is urethral catheterization of a pelvic fracture patient safe? If there is no blood present at the meatus, a gentle attempt at urethral catheterization may be made. It has been sugge sted that this could con- vert a partial urethral rupture into a complete rupture. However, lead- ing trauma centers in the United States state \200\230We and others have not seen a ny evidence that this can convert an incomplete into a complete transection \200 and we u sually make one gentle attempt to place a urethral catheter in suspected urethral disruptio n \200\231.1 If any resistance is encoun- tered, stop and obtain a retrograde urethrogram. If the retrograde ure- throgram demonstrates a normal urethra, proceed with another attempt at catheterization, using plenty of lubricant. If there is a urethral rupture, insert an S PC via a formal open approach to allow inspection of the blad- der (and repair of injuries if present). Bladder injuries associated with pelvic fractures Ten percent of male and 5% of female pelv ic fractures are associated with a bladder injury (fracture type leading to bladder injury is usually an an- teroposterior pelvic compression fracture, i.e. open book pelvic fracture ; Tile classi \201 cation B1). Sixty percent of pelvic fracture bladder ruptures are extra peritoneal, 30% intraperitoneal, and 10% combined extraperitoneal and intraperitoneal. CHAPTER 11 Trauma to the urinary tract 528 Table 11.3 The Tile classi \201 cation system of pelvic ring fractures Type A \200\224stable A1: fracture of pelvis not involving the pelvic ring A2: minimal displacement of pelvic ring with no instability Type B \200\224rotationally (horizontally) unstable B1: open book B2: closed book Lateral compression: ipsilateral fracture B3 closed book Lateral compression: contralateral fracture (bucket handle fracture) Type C \200\224rotationally (horizontally) and vertically unstable C1: unilateral C2: bilateral C3: with acetabular fracture Urethral injuries associated with pelvic fractures The posterior urethra (essentially the m embranous urethra) is injured with roughly the same frequency as the bladder in subjects wh o sustain a pelvic fracture, occurring in 5 \200\22315% of such cases. Most posterior ureth ral injuries occur in association with pelvic fractures.2 Cass found bladder ruptures in 6% of pelvic fractures, urethral rupture in 2%, and combined bladder and urethral rupture in 0.5%.3 Combined bladder and posterior urethral injuries following pelvic fracture One-third of pat ients with a traumatic bladder rupture have injuries to other urinary structures, most comm only the urethra. Ten to twenty per- cent of patients with a pelvic fracture and bladder ru pture also have a posterior urethral rupture. Symptoms and signs of bladder or urethral injury in pelvic fracture - Blood at meatus \200\224in 40 \200\22350% of patients (no blood at meatus in 50 \200\22360% ). Gross haematuria. Inability to pass urine. Perineal or scrotal bruising. \200\230High r iding \200\231 prostate. Inability to pass a urethral catheter. - - - \200\230High riding prostate \200\231 The prostate and bladder become detached from the me mbranous ure- thra and are pushed upwards by the expanding pelvic haematoma. The high ridin g prostate is said to be a classic sign of posterior urethral rupture. Traditional teaching states that a DRE should be done in cases of pelvic PELVIC FRACTURES: BLADDER AND URETERIC INJURIES 529 trauma to determine prostatic position. However, the presence of a high riding prostate is an unreliable sign.4 The pelvic haematoma may make it impossible to feel the prostate so th e patient may be thought to have a high riding prostate when, in fact, it is in a normal po sition. Conversely, what may be thought to be a normal prostate in a normal position may ac tually be the palpable pelvic haematoma. In pelvic fracture, a DRE is done not to identify a high riding prostate, but rather to establish the pres- ence of an associated rectal inju ry (blood seen on the examining \201 nger). However, rectal injury can still occur in the absence of rectal blood. Fig. 11.7 An open book pelvic fracture before \201 xation. Fig. 11.8 An open book pelvic fracture after \201 xation. CHAPTER 11 Trauma to the urinary tract 530 Management of bladder injuries associated with pelvic fractures Extraperitoneal: urethral c atheter until the bladder has healed (usually 2 \200\2233 weeks). Intraperitoneal: open sur gical repair.