Genitourinary Trauma, Management of

Authors

EAST Practice Management Guidelines Work Group

Michele Holevar, MD, Mount Sinai Hospital/Chicago Medical School
James Ebert, MD, Elmhurst Memorial Hospital
Fred Luchette, MD, Loyola University Medical Center
Kim Nagy, MD, John H. Stroger, Jr. Hospital of Cook County
Rob Sheridan, MD, Massachusetts General Hospital
J. Patrick Spirnak, MD, Case Western Reserve University
Charles Yowler, MD, Case Western Reserve University

Address for Correspondence and Reprints

Michele Holevar, MD
Mount Sinai Hospital/Chicago Medical School
1500 South California Avenue F938
Chicago, IL 60612
Phone: 773-257-6880
Email: mrholevar@cs.com

I. Statement of the problem

As our ability to image the genitourinary tract improves, and the concept of nonoperative management of solid organ injury has extended to include renal trauma, the optimal methods of managing injuries to the genitourinary tract have remained controversial. New methods of management, including laparoscopic techniques, complement and, in some cases, supplant traditional techniques.

We initiated our review of management of genitourinary trauma by generating several questions:

1. What are the indications for operative exploration of the kidneys in blunt trauma? In penetrating trauma?
2. How should renal function be assessed intraoperatively if contralateral nephrectomy is contemplated?
3. What is the trigger for exploration of the kidneys following initial nonoperative therapy? Number of PRBCs transfused? Expanding hematoma on repeat CT scan? Urinoma?
4. If nonoperative therapy is selected, is radiographic follow-up required?
5. What are the indications for exploration of the renal vessels in blunt trauma? What is the time frame for operative exploration of the renal vessels in blunt trauma? In which patients should renal vascular repair be attempted? Which patients should undergo primary nephrectomy?
6. What are the indications for operative exploration of the bladder after blunt trauma? After penetrating trauma?
7. If nonoperative therapy of a bladder injury is selected, should a suprapubic tube or a transurethral catheter be utilized?
8. How should the integrity of the ureter be assessed intraoperatively?

II. Process

A. Identification of references

A computerized search was undertaken using Medline with citations published between the years of 1966 and 2003. Using the search words genitourinary, renal, kidney, ureter, bladder, urethra, renovascular, trauma, wounds, and injury, and by limiting the search to citations dealing with human subjects and published in the English language, we identified over 3,300 articles. From this initial search, case reports, review articles, editorials, letters to the editor, pediatric series, and meta-analyses were excluded prior to formal review. Additional references, selected by the individual subcommittee members, were then included to compile the master reference list of 129 citations.

Articles were distributed among the subcommittee members for formal review. A data sheet was completed for each article reviewed which summarized the purpose of the study, hypothesis, methods, main results, and conclusions. The reviewers classified each refence by the
methodology established by the Agency for Health Care Policy and Research (AHCPR) of the U.S. Department of Health and Human Services.

B. Quality of the references

Class I: Prospective randomized controlled trials. (1 reference)

Class II: Clinical studies in which the data was collected prospectively, and retrospective analyses were based on clearly reliable data. Types of studies so classified include: observational studies, cohort studies, prevalence studies, and case control studies. (4 references)

Class III: Studies based on retrospectively collected data. Evidence used in this class includes clinical series and database or registry review. (123 references)

An evidentiary table was constructed using the remaining 128 references. Recommendations were based on studies included in the evidentiary tables.

III. Recommendations

A. Renal Trauma

1. Level I

There is insufficient Class I and Class II data to support any standards regarding management of renal trauma.

2. Level II

1. Preliminary vascular control does not decrease blood loss or increase renal salvage.
2. Conservative management of shattered but perfused kidneys in hemodynamically stable patients with minimal transfusion requirements will result in a low incidence of complications, which can usually be treated with endourological or percutaneous methods.

3. Level III

1. Preliminary vascular control may prolong operative time
2. The success of nonoperative management may be enhanced by the use of angiographic embolization.
3. Nonoperative treatment of renal lacerations from blunt trauma associated with extravasation is associated with few complications, which can usually be treated with endourological or percutaneous methods.
4. Conservative management of major renal lacerations associated with devascularized segments is associated with a high rate of urologic morbidity (38–82%). In patients who present with a major renal laceration associated with devascularized segments, conservative management is feasible in those who are clinically stable with blunt trauma. The physician must be especially aware of the probable complications within this subset of patients.
5. Operative exploration of the kidney should be considered in patients with major blunt renal injuries with a devascularized segment in association with fecal spillage or pancreatic injury.
6. Nonoperative treatment of penetrating renal lacerations is appropriate in hemodynamically stable patients without associated injuries hwo have been staged completely with CT scan and/or IVP. A high index of suspicion is needed to avoid ureteral injuries if a course of nonexploration is chosen.
7. Penetrating Grade III or IV injuries are associated with a significant risk of delayed bleeding if treated expectantly. Exploration should be considered if laparotomy is indicated for other injuries or if the injury is not completely staged prior to exploratory laparotomy for other injuries.

B. Renovascular trauma

1. Level I

There is insufficient Class I and Class II data to support any standards regarding management of renovascular trauma.

2. Level II

There is insufficient Class II data to support any recommendations regarding management of renovascular trauma.

3. Level III

There is insufficient Class III data to support any recommendations regarding management of renovascular trauma.

C. Ureteral trauma

1. Level I

There is insufficient Class I and Class II data to support any standards regarding management of ureteral trauma.

2. Level II

There is insufficient Class II data to support any recommendations regarding management of ureteral trauma.

3. Level III

There is insufficient Class III data to support any recommendations regarding management of ureteral trauma.

D. Bladder trauma

1. Level I

There is insufficient Class I and Class II data to support any standards regarding management of bladder trauma.

2. Level II

There is insufficient Class II data to support any recommendations regarding management of bladder trauma.

3. Level III

1. Conservative, nonoperative management of blunt extraperitoneal bladder rupture has a similar outcome to that of patients treated with primary suturing.
2. Transurethral catheters result in fewer complications and fewer days of catheterization than suprapubic catheters, regardless of the degree of bladder injury, and are therefore preferable to suprapubic catheters whether the patient is being treated nonoperatively or operatively.

E. Urethral trauma

1. Level I

There is insufficient Class I and Class II data to support any standards regarding management of urethral trauma.

2. Level II

There is insufficient Class II data to support any recommendations regarding management of urethral trauma.

3. Level III

Posterior urethral injuries secondary to blunt trauma may be treated either with delayed perineal reconstruction or primary endoscopic realignment, resulting in equivalent outcomes.

IV. Scientific foundations

A. Renal trauma

The kidney is the most frequently injured urologic organ, with 70% ot 80% being a consequence of blunt trauma. Although few urologic injuries are immediately life-threatening, they do account for some of the more frequent complications of trauma. Nonoperative management of renal injuries was begun in an attempt to avoid the high nephrectomy rates associated with renal exploration in early series. Widespread use of computed tomography has demonstrated spontaneous healing of ruptured kidneys. In a retrospective study comprised of 126 patients with blunt renal injury, 90% were treated conservatively^[14]. Overall, results were excellent in 87%; there were four deaths unrelated to the renal injury and two patients who required dialysis In another review of 55 patients with renal trauma (95% blunt) by Goff et al, 69% of hemodynamically stable patients and 38% of hemodynamically unstable patients were successfully managed nonoperatively. Operative exploration was primarily required for the treatment of associated injuries^[8].

Cheng et al found, in their series of 16 patients with CT-identified Grade III renal injuries (eight blunt and eight penetrating), 13 (81%) were successfully managed nonoperatively^[26]. The three patients who underwent immediate exploratory laparotomy did so for associated injuries. Two of the patients managed nonoperatively developed complications, a urinoma requiring percutaneous drainage and a urinary fistula which was repaired operatively.

In a retrospective review of 13 patients with Grade V blunt renal injury, six hemodynamically stable patients with a shattered but perfused kidney were successfully treated nonoperatively. Seven patients with either a nonperfused kidney or hemodynamic instability were treated operatively. The nonoperative group had fewer ICU days, significantly lower transfusion requirements, and fewer complications. A follow-up CT scan of nonoperatively treated patients revealed a functioning kidney in four of the six patients in which it was performed. No patients subsequently developed hypertension, leading the authors to conclude that conservative management of shattered but perfused kidneys is feasible in hemodyamically stable patients with minimal transfusion requirements^[1].

This data was supported by a review of 23 consecutive patients with major blunt renal rupture^[16]. The first group of 12 received operations for hemodynamic instability or persistent extravasation. Surgery was reserved only for major complications in the second group of 11. In the first group, six patients underwent early exploration, resulting in five nephrectomies. In the second group, nonoperative management was uniformly successfully, although four patients required ureteral stents. The authors concluded that in most patients with blunt renal lacerations, conservative therapy is safe. They found that most extravasations spontaneously resolve and minimally invasive techniques will deal with nearly all complications. In their series, renal exploration usually resulted in nephrectomy.

The effect of devascularization was examined in a case series of 20 conservatively managed patients with either Grade IV (15) or Grade V (five) blunt renal injury with urinary extravasation, including 11 patients with devitalized tissue. There was a statistically significant difference in the length of hospital stay (16.3 vs 7.3 days), blood transfusions (six vs two patients, P < 0.08) and the need for delayed surgical intervention (nine vs two, P < 0.01) between patients with and with no devitalized segments, respectively. Urinary extravasation spontaneously resolved in two of 11 patients with and in seven of nine with no devitalized segment, respectively (P < 0.05) The authors concluded that even in the presence of a devascularized segment, conservative management is an appropriate method of therapy for the clinically stable patient.^[102] .

In another series of 43 hemodynamically stable patients with a devascularized renal segment between 25 and 50%, expectant management resulted in urologic complications in 85% with an associated 6% risk of nephrectomy^[29]. Infected urinomas and perinephric abscesses seeded by coexisting enteric or pancreatic injuries were the most common complication, suggesting that renal exploration and surgical repair significantly improve the prognosis only in patients with simultaneous intraperitoneal and renal injuries (p < 0.01). Shapiro et al analyzed a state database to determine if neurologic impairment impacted the success of nonoperative therapy of solid organ injuries secondary to blunt trauma, including the kidney^[90]. They found that there was no difference in the nonoperative failure rate between patients with normal mental status and those with mild to moderate or severe head injuries. Therefore, the literature supports conservative management of shattered but perfused kidneys in hemodynamically stable blunt trauma patients with minimal transfusion requirements. Although persistent extravasation or urinoma can be expected, they can usually be treated with endourological or percutaneous methods.

The management of penetrating wounds to the kidney is similarly evolving. Velmahos et al prospectively identified 79 patients with truncal penetrating wounds involving the urinary tract^[10]. Five (6 per cent) patients were managed non-operatively and 16 (20 per cent) more underwent abdominal but not renal exploration. From 21 (26.5 per cent) cases with complications, only three (4 per cent) patients developed complications which were associated with the urinary tract injuries. They advised that, although the majority of patients with gunshot wounds of the urinary tract will require abdominal exploration, invasion of Gerota's fascia may be spared in cases of stable renal hematomas.

Peterson et al reviewed their experience with 60 penetrating renal injuries, of which 42 were explored. Retrospectively determining which patients had unnecessary renal explorations, they deemed 27/60 (45%) to have required renal exploration. In hemodynamically stable patients, they recommended retroperitoneal dissection only if preoperative or intraoperative assessment suggests a major renal injury with extravasation outside of Gerota's fascia, suspicion exists of significant nonurologic retroperitoneal injury (great vessels, duodenum, pancreas, color), and/or inspection demonstrates an expanding or pulsatile retroperitoneal hematoma^[61].

In a more recent series of 244 patients with renal-proximity stab wounds, a total of 43 injuries were found on IVP, CT, and angiogram. 18/23 patients with minor injuries were managed nonoperatively, and 9/10 patients with vascular injuries were managed successfully with transcatheter embolization. All patients with Grades III or IV injuries were explored. Eastham et al concluded that most renal injuries, when accurately staged, can be safely managed nonoperatively^[30].

In a review of 120 patients with Grades II to IV renal lacerations secondary to penetrating trauma, 41 were treated nonoperatively and 70 underwent immediate renal exploration. In patients with Grade II injuries, no complications resulted from nonoperative treatment. 23.5% of patients with Grades III and IV injuries treated nonoperatively experienced delayed renal bleeding, compared to none of the operatively treated patients with Grade III and IV injuries. The authors concluded that Grade II injuries in hemodynamically stable patients can be treated nonoperatively, noting that Grades III and IV injuries are associated with a significant risk of bleeding if treated expectantly^[15]. Therefore, nonoperative treatment of penetrating renal injuries is appropriate in hemodynamically stable patients without associated injuries who have been staged completely with CT scan and/or IVP. Exploration should be considered if laparotomy is indicated for other injuries or if the injury is not completely staged prior to exploratory laparotomy for other injuries.

When required for renal injury, nephrectomy is usually due to renal hemorrhage. Carlton first suggested that the nephrectomy rate could be decreased by early control of the renal vasculature^[123] . In a retrospective review, McAninch found that from 1964 to 1973, their nephrectomy rate was 56%. From 1977 to 1981, they gained control of the renal artery and vein prior to entering Gerota's fascia, with a reduction in their nephrectomy rate to 18%^[124]. This, however, has been challenged by several subsequent publications.

Atala et al reviewed 75 patients requiring renal exploration for either penetrating or blunt renal injury. They obtained vascular control prior to opening Gerota's fascia in 32 patients and after opening Gerota's fascia in 43 patients. The nephrectomy rate was found to depend on the degree of injury rather than on the type of renal vascular control obtained. Not only did obtaining vascular control after opening Gerota's fascia not increase the nephrectomy rate, but it was found to shorten operative time by an average of 58 minutes^[121].

In a series of 85 explorations for penetrating (66) and blunt (19) trauma, Corriere et al found although formal pedicle control was carried out 33 times, it was never necessary to control parenchymal hemorrhage. They concluded that entering a large retroperitoneal hematoma in the midline to obtain control of the vessels added time to the procedure but little else. They suggested that perirenal hematomas can be safely entered laterally without prior pedicle control using manual pedicle or parenchymal control if needed, reserving formal pedicle control for those wounds overlying the great vessels^[36].

The validity of this suggestion was supported by a prospective, randomized trial of 56 patients with penetrating renal injuries, of whom 29 patients received preliminary vascular control and 27 patients received no vascular control prior to opening Gerota's fascia^[2]. Gonzalez et al found no difference in the nephrectomy rate or units of blood transfused comparing these two groups, but did find a statistically significant increase in average operative time associated with preliminary vascular control. The authors concluded that vascular control of the renal hilum prior to opening Gerota's fascia has no impact on nephrectomy rate, transfusion requirements, or blood loss, although it may prolong operative time.

B. Renovascular trauma

Blunt renovascular trauma is a fairly rare injury. Although the diagnosis is being made more commonly and earlier with the use of sophisticated computerized tomography, there is very little published information regarding the optimal timing and treatment of these injuries. The available literature consists of case series comprised of fewer than ten cases per report. The success of revascularization in these publications is low, and although it has been suggested that repair should be attempted in stable patients with unilateral injury within a certain time period, there is no data to support this recommendation. Further confusing the issue are isolated reports of patients regaining renal function when revascularized 19 hours after injury^[129]. Due to the paucity of data, we were unable to make any recommendations with regard to renovascular trauma.

C. Ureteral trauma

Ureteral injuries are uncommon, accounting for only 17% of penetrating urologic trauma. The majority of publications in the English literature is comprised of case reports and small case series, making it difficult to make any meaningful conclusions. The largest case series to date, reported by Perez-Brayfield et al, reviewed 118 patients with gunshot wounds to the ureter. A variety of surgical procedures were used to repair the defect, depending on the location and severity of the defect. Complications occurred in 24 patients. The authors concluded that a high index of suspicion is essential to avoid missing these injuries^[115].

In some instances, patients may be too hemodynamically unstable to tolerate a ureteral repair, and definitive repair must be deferred. In a retrospective review of 41 patients with ureteral injury associated with other injuries, Velhamos et al found that three patients died and 11 (26.8%) developed complications. All 6 ureteral dehiscences developed in the 30 patients with associated colonic injury (20%). These authors concluded that the presence of shock on admission or severe colonic injury requiring colectomy precludes ureteral repair, and suggested ureteral exteriorization or primary nephrectomy in these circumstances^[19].

D. Bladder trauma

Extraperitoneal bladder rupture occurs in approximately 60 - 65%%, intraperitoneal rupture in 25%, and combined intraperitoneal and extraperitoneal rupture in 10 - 15%. Intraperitoneal bladder injuries have uniformly been repaired surgically, whereas extraperitoneal ruptures are more controversial. In a number of series, conservative, nonoperative management of blunt extraperitoneal bladder rupture has had a similar outcome to that of patients treated with primary suturing.

Corriere reviewed 100 cases of bladder rupture, of which 62 were extraperitoneal and 59 were associated with pelvic fractures. Complex injuries with extravasation outside the confines of the perivesical space were noted in 42% of the patients. The area of bladder injury was unassociated with the area of the pelvic fracture in 65% of their patients. Forty-one patients were treated with bladder drainage alone. Fourteen patients underwent formal closure with cystostomy tube placement, and seven died before institution of therapy. Cystograms ten days after injury demonstrated no extravasation in 36 of the 41 patients treated with similar catheter drainage. In all five patients with persistent extravasation, the bladder wound eventually healed spontaneously without complications. The authors concluded that both male and female patients with any size lesion and with any amount of extravasation can be treated successfully with simple catheter drainage. They also recommended that if the patient was to be explored for another region, the bladder injury should be repaired if the pelvic hematoma can be avoided^[45].

In a retrospective review of 164 cases of bladder rupture, of which 57.5% were extraperitoneal, 30 of the extraperitoneal injuries were treated conservatively with a transurethral catheter and one was treated by a percutaneous suprapubic cystostomy alone. Of these patients, two had complications related to the method of management: clot retention in one and formation of a pseudodiverticulum around a bone spike projecting into the bladder that required delayed surgical closure in one. The authors advised that nonoperative management of extraperitoneal rupture was successful in most
cases.^[48]

This statement was supported by a review of 111 patients with bladder ruptures (95 blunt), 39 of 58 patients with extraperitoneal bladder injuries were treated with catheter drainage alone. Patients preferentially received conservative treatment despite the size of the rupture and only underwent formal repair if explored for another reason. Transurethral catheters were used in 30 cases, percutaneous cystostomy in four cases, and five patients had a cystostomy tube placed at the time of exploration for other abdominal injuries. They did not administer antibiotics routinely and they saw no septic complications or pelvic abscesses. Followup cystograms 10 days after the injury showed
no extravasation in 34 (87%) of the 30 patients treated in this manner. All 39 patients did well without complications. The authors concluded that patients with extraperitoneal bladder ruptures may be treated with simple catheter drainage, if not requiring exploration for associated injuries^[54].

In another series of 105 cases of extraperitoneal bladder rupture, 65 cases treated with operative repair were compared to 34 patients who received catheter drainage alone. There were three early complications in the group treated by suturing (hematuria with clot retention 2, sepsis contributing to death 1) and four early complications in the conservatively treated group (hematuria with clot retention, pseudodiverticulum with bone spike in its floor, persistent urinary fistula, and sepsis contributing to death one). There were two late complications in 42 patients followed in the group treated by suturing (urethral stricture, frequency and dysuria), and three late complications in 14 patients followed in the conservatively treated group (hyperreflexic bladder, urethral stricture and vesical calculi). Although the early and late complication rates were higher in the conservatively managed group, there was no statistically significant difference from the group treated by primary suturing. The authors reported that poor outcome might be most common in patients with severe pelvic fracture^[98].

Therefore, the consensus in the literature is that the majority of extraperitoneal bladder ruptures can be managed with catheter drainage alone. Relative contraindications to conservative management include bone fragments projecting into the bladder, open pelvic fractures, and bladder injuries associated with rectal perforations.

It has been traditional to achieve bladder drainage with a large-bore suprapubic cystostomy catheter alone or in additional to a transurethral catheter in order to ensure drainage of blood and clots. This teaching has been challenged in the recent literature. In a retrospective analysis of 47 patients with traumatic bladder injuries (18 blunt and 29 penetrating) requiring bladder repair, 16 patients were treated with a suprapubic catheter, 27 with a transurethral catheter and 4 with a suprapubic and temporary transurethral catheter. All seven urinary complications were noted in patients with suprapubic catheters. The average catheter duration was 42 days in the suprapubic group versus 13 days in the transurethral group. The authors concluded that transurethral catheters result in fewer complications and fewer days of catheterization, regardless of the degree of bladder injury^[9].

Volpe et al reviewed 34 patients with bladder injury (82% penetrating, 18% blunt). Following primary repair, 18 patients were drained with suprapubic tubes and 16 were trained with transurethral catheter alone. Urologic complications were found in 28% of the suprapubic tube group versus 19% of the urethral catheter group. The authors suggested that intraperitoneal bladder injuries may be equally well managed by primary bladder repair and transurethral catheter drainage alone versus suprapubic tube drainage^[96]. Transurethral catheters for management of blunt and penetrating bladder trauma are effective, cause less morbidity, and may be removed more rapidly that suprapubic catheters for any degree of bladder injury.

E. Urethral trauma

Urethral injury is usually secondary to blunt trauma, occurring in 5 to 10% of cases of pelvic fracture. The management of urethral distraction injury has changed over the years. The primary options include delayed operative reconstruction or primary stenting of the injury with a urethral catheter, which may be endoscopically-assisted.

In a retrospective review of 77 cases of traumatic posterior urethral injury, delayed repair (median time to repair of 12 months) resulted in adequate urethral continuity in 94l.8%. Postoperative incontinence occurred in 9% and postoperative erectile dysfunction in 16%^[11].

Herschorn et al, in a retrospective series of 20 patients with prostatomembranous urethral disruptions, reported a 96% urethral stricture rate requiring posterior urethroplasty associated with suprapubic tubes, compared to 31% of patients who underwent early transurethral catheterization^[106].

Kotkin et al reviewed 32 patients with urethral disruptions; 20 with complete injuries were treated with immediate realignment and 12 with partial or complete injuries were treated with retrograde catheterization alone. They reported similar complication rates in the two groups^[107].

A series of 57 patients with posterior urethral disruptions treated with primary urethral realignment within six hours of injury reported no impotence in 79%, with impotence requiring treatment in only 7.5%. Only 3.7% experienced mild stress incontinence, not requiring treatment. Although 68% had evidence of post-realignment strictures, 43% were either simply observed or managed with in-office dilation^[104].

Follis et al compared 33 patients with complete prostatomembranous urethral disruptions. Twenty were managed by immediate realignment, while 13 were managed with initial suprapubic tube and delayed urethroplasty. Immediate realignment resulted in an overall potency rate of 80%, compared to only 50% in patients who underwent delayed repair. There was an increased need for a secondary operation when the repair was delayed. Continence rates were similar in both groups^[105] . Therefore, it appears as if posterior urethral injuries secondary to blunt trauma may be treated either with delayed perineal reconstruction or primary endoscopic realignment.

V. Summary

The urinary tract may be damaged by a variety of blunt or penetrating trauma to the abdomen. Urinary system injuries occur in approximately 4% of trauma patients. When multiple injuries coexist in the patient with urinary tract trauma, injuries to the urinary tract must be assessed as to their contribution to the immediately life-threatening situation. Although our subcommittee generated innumerable questions regarding the management of urinary tract injuries, we were able to satisfactorily answer only a few.

VI. Future investigations

There is a paucity of Class I data analyzing the various methods of managing genitourinary tract trauma, as evidenced by the complete lack of Level I recommendations for the management of these injuries. Future investigations should be carried out in a prospective, randomized manner with a sufficient number of patients to enable clinicians to draw valid, concrete conclusions as to the optimal methods of managing these patients. Unanswered questions remain as to the best way to assess renal function and ureteral integrity intraoperatively and the optimal timing and management of blunt renovascular trauma. Although it is now acceptable to manage selected patients with renal trauma nonoperatively, the indications to declare nonoperative management unsuccessful are not clear. As physicians and health care systems become increasingly more fiscally responsible, the indications for radiographic follow-up in nonoperatively managed patients also need to be addressed. Given the relative infrequency of some of these injuries, especially renovascular trauma, these investigations may require large-scale multi-institutional projects.

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Evidentiary Table