Urological trauma and emergencies

Published on 14/03/2015 by admin

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Chapter 19 Urological trauma and emergencies

Phillip C. Brenner

RENAL TRAUMA

Initial assessment

Penetrating. < 15% of all renal trauma, usually gunshot or knife. Will usually be explored for associated injuries. CT with contrast necessary (or intravenous pyelogram (IVP) if CT not available) to ensure contralateral kidney function and to assess disruption of urinary collecting system.

Blunt. 85% of all renal trauma. Most will be conservatively managed.

Indications of radiological imaging

• Gross haematuria
• Microscopic haematuria as well as:

• hypotension (systolic < 90 mmHg) any time since accident
• suggestive injury—fall > 3 m, flank bruising; direct blow; deceleration injury > 60 kph
• suggestive associated injury—fractured lumbar vertebrae; fractured lower ribs

• Microscopic haematuria alone followed up electively with CT kidney-ureter-bladder (KUB) with IV contrast to exclude preexisting disease (e.g. polycystic kidney)

Type of imaging

CT with contrast. Look for:

• contralateral functioning kidney
• delayed or absent function in affected kidney
• contrast extravasation.

Management

General

1. Blood and fluid replacement
2. Assessment of associated injuries
3. Conservative for stable patients with functioning kidney and minor extravasation only

Surgical exploration—acutely

• Unstable patient due to haemorrhage
• Major extravasation due to shattered or bisected kidney
• Renal pedicle disruption
• Continued subacute haemorrhage
• Urinoma with sepsis

Ureteric injury or pelviureteric disruption

Rare except in children. This is typically a deceleration injury. Diagnosed in CT KUB with IV contrast.

Rupture of bladder or posterior urethra

This is usually due to a fractured pelvis. Occasionally a stab wound or seat belt injury will rupture a full bladder.

Seat belt or knife wound

• Associated injuries may need to be explored.
• Cystogram (see below) is performed.
• Minor extraperitoneal rupture may be managed with catheter drainage alone.
• Major extraperitoneal or intraperitoneal rupture must be repaired.

Fractured pelvis

• The patient is often shocked and requires resuscitation.
• There is a tender mass suprapubically which may be a pelvic haematoma or a full bladder. Bedside ultrasound is very useful.
• There may be blood at the urethral meatus.
• Urinary retention is usually the rule, but urine may have been passed and should be examined for blood.

Management of stable patient

1. If there is no blood at the meatus, a 15 Fr or 18 Fr catheter may be gently passed. If there is no macroscopic blood, no further imaging is necessary.
2. If there is blood at the meatus, a urethrogram is performed.

a. Commonly a complete rupture of the prostatomembranous urethra will be seen. This will require exploration or suprapubic diversion. There is often associated rupture of bladder—ultrasound will identify a full bladder.
b. If the urethra is intact, the catheter is advanced into the bladder and a formal cystogram is performed.

3. Cystogram—350 mL of water-soluble contrast are instilled unless extravasation is seen. The bladder is drained and post-drainage films are examined for extravasated contrast.
4. Limited extraperitoneal rupture may occasionally be managed with catheter drainage, but most major extraperitoneal and all intraperitoneal leakages are explored and repaired.
5. CT KUB with IV contrast must be performed to exclude associated ureteric or renal injury.

Management of unstable patient

In an unstable patient who is going to laparotomy with blood at meatus:

1. A gentle attempt to pass a catheter should be made by experienced staff.
2. If the catheter enters the bladder a CT KUB with IV contrast and cystogram should be performed as time permits.

Surgical management

Surgical management will be to repair bladder, place suprapubic diversion and attempt to stent urethral disruption with urethral catheter.

Rupture of bulbar urethra

This is due to a fall-astride injury, e.g. onto the crossbar of bicycle, cutting the bulbar urethra between the pubic bone and bar. There is:

• blood at the meatus
• ‘butterfly’ bruising in perineum, and scrotal swelling
• urinary retention.

Treatment

1. Retrograde urethrogram to establish whether tear is complete.
2. Suprapubic stab cystotomy for drainage.
3. For incomplete tears, a catheter will be passed under X-ray control to try to stent the urethra.
4. Complete tears need surgical exploration and re-anastomosis either at time of injury or when bruising settles.

Renal colic

Clinical presentation

• Severe flank pain radiating around to groin, testis or labia.
• Patient rolls around unable to find comfortable position, sweats and may be pale, sometimes vomits.
• Low stones present with ill-defined lower pain and extreme desire to pass urine with empty bladder. (May present with ‘retention’ but there is no urine in bladder.)
• Microscopic or macroscopic haematuria is present in over 90% of cases.
• Stone will be seen on X-ray in 85%.

Note: Ureter runs across tip of transverse processes of L2– L5, upper and lower sacroiliac joint and next to ischial spine. Ureteric orifice is medial, near coccyx.

• Patient has often had renal colic before. In older patients with first episode, suspect aortic aneurysm.

Initial assessment

1. Exclude: (a) peritonitis (rigid abdomen); (b) fever; (c) urinary retention.
2. Administer analgesia: (a) IV morphine or pethidine; (b) antiemetic metoclopramide or procholorperazine; (c) indomethacin 100 mg suppository; (d) hyoscine 20 mg IV may help less severe pain.
3. Test for haematuria.
4. Non-contrast CT KUB to identify stone and plain X-ray to see if it is radio-opaque (i.e. calcium) or radiolucent (i.e. uric acid).

Indications for admission

• Absolute: (a) ongoing or unrelieved pain; (b) fever > 37.5°C; (c) anuria or serum creatinine > 0.20 mmol/L; (d) known solitary kidney
• Relative: (a) stone > 8 mm seen on KUB; (b) diabetes; (c) background renal compromise; (d) re-presentation with pain
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