a review of urological

trauma guidelines
Arif Hidayat
Stase urologi oktober 2018
 INTRODUCTION
• Injury to the genitourinary tract occurs in 10% of abdominal
trauma
• To aid in appropriate treatment :
- EAU released guidelines on urological trauma in 2014,
updated 2018
- AUA guidelines on urological trauma were released in
2014 and amanded 2017
- Societe Internationale d’Urologie(SIU) in 2004
• The AAST has developed a grading system of organ injury
severity
• This article summarises the guidelines including the level of
evidence of each recommendation
 Renal Trauma
• the kidney is the most commonly injured genitourinary organ,
particulary vulnerable to deceleration injuries
• in the USA, 80% of kidney injury is due to blunt trauma
• Evaluation of renal trauma : Haemodinamic status,
mechanism of injury, phisical examination, and urine analysis
• Hematuria is present in 80-94% of case
 Evaluation of Renal Trauma
• The first step in the EAU, and AUA guidelines for renal trauma
is evaluation of the patient’s HD status (Grade A, EAU)

(EAU, 2018)
 Evaluation of Renal Trauma
• Stable patients with gross haematuria or microscopic
haematuria and hipotensi (SBP < 90 mmHg) should undergo
imaging (Grade B, AUA).
• Imaging is also indicated if the mechanism of trauma
concerning for renal injury (rapid deceleration, significant
blow to flank, significant flank ecchymosis, penetrating injury
of abdomen, flank, or lower chest). (Grade C, AUA)
• Generally, children can be imaged using the same criteria as
adults (AUA, 2017).
(EAU, 2018)
 Treatment
AUA 2017:
• Clinicians should use non-invasive
management strategies in
hemodynamically stable patients
with renal injury. (Grade B)
• Conservative management is also
recommended for grade 3 or 4
injuries(Grade B)
• for 5th recommends observation
for hemodynamically stable
patients regardless of AAST
grade, due to interobserver
variability regarding classification
of grade 4 and 5 injuries (Grade
B)
EAU 2018
• All grade 1 and 2 injuries, either
due to blunt or penetrating
trauma, can be managed non-
operatively.
• For the treatment of grade 3
injuries, most studies support
expectant treatment (Grade B)
• isolated grade 4 injuries, the EAU
states that treatment is based
solely on the extent of the renal
injury
• for 5th the EAU only
recommends renal exploration if
the injury is vascular (Grade B).
• The surgical team must perform immediate intervention
(surgery or angioembolization in selected situations) for
haemodynamically unstable patients (Grade B, AUA;Grade A,
EAU).
• During laparotomy for renal trauma, the EAU and AUA
guidelines give the option of performing a ‘one-shot’ i.v.
urogram (IVU) before retroperitoneal exploration (Grade C,
AUA)
• EAU guidelines state that renal reconstruction should be
attempted once haemorrhage is controlled (Grade B, EAU).
However, the AUA guidelines state that the benefit of prior
vascular control is inconclusive (Grade B, AUA).
 Follow up
• Follow-up CT if the patient has fever, increasing flank pain or
falling haematocrit level (Grade B, EAU)
• The AUA guidelines recommend follow-up imaging for grade 4
or 5 injuries at 48 h (Grade C, AUA)
• While the EAU and SIU guidelines recommendnuclear renal
scan for follow-up (Grade C, EAU), the AUA guidelines
recommend against routine nuclear renal scans due to
inadequate benefits (Expert Opinion, AUA)
Evaluation of Blunt renal truama in adult, (EUA, 2018)
Evaluation of Penetrating renal truama in adult, (EUA, 2018)
 Ureteral Trauma
• The least common type of genitourinary
• Due to the small size, mobility, and protected location
• The most common cause is iatrogenic trauma
• The lower third of the ureter is the most commonly injured
• Treatment based on severity and location of the injury
• Perform IV contrast enhanced abdominal/pelvic CT with delayed imaging (urogram) for
stable trauma patients with suspected ureteral injuries. (AUA: Grade C)
• Repair traumatic ureteral lacerations at the time of laparotomy in stable patients. (AUA:
Grade C)
• Manage ureteral injuries in unstable patients with temporary urinary drainage followed
by delayed definitive management. (Clinical Principle)
• manage traumatic ureteral contusions at the time of laparotomy with ureteral stenting
or resection and primary repair depending on ureteral viability and clinical scenario.
(Expert Opinion)
• attempt ureteral stent placement in patients with incomplete ureteral injuries
diagnosed postoperatively or in a delayed setting. (Recommendation; Evidence
Strength: Grade C)
• perform percutaneous nephrostomy with delayed repair as needed in patients when
stent placement is unsuccessful or not possible. (Recommendation; Evidence Strength:
Grade C)
• initially manage patients with ureterovaginal fistula using
stent placement. In the event of stent failure, clinicians may
pursue additional surgical intervention. (Expert Opinion)
• Repair ureteral injuries located proximal to the iliac vessels
with primary repair over a ureteral stent, when possible.
(AUA: Grade C)
• repair ureteral injuries located distal to the iliac vessels with
ureteral reimplantation or primary repair over a ureteral
stent, when possible. (AUA: Grade C)
EAU, 2018
• Manage endoscopic ureteral injuries with a ureteral stent
and/or percutaneous nephrostomy tube, when possible.
(AUA: Grade C)
• Manage endoscopic ureteral injuries with open repair when
endoscopic or percutaneous procedures are not possible or
fail to adequately divert the urine. (Expert Opinion)

EAU, 2018
EAU, 2018
 Bladder Trauma

• Bladder injuries can be divided into extraperitoneal (60%), and

intraperitoneal (30%)

• Clinicians must perform retrograde cystography (plain film or CT) in

stable patients with gross hematuria and pelvic fracture. (AUA:
Grade B
• perform retrograde cystography in stable patients with
gross hematuria and a mechanism concerning for
bladder injury, or in those with pelvic ring fractures and
clinical indicators of bladder rupture. (AUA: Grade C)
• Surgeons must perform surgical repair of intraperitoneal
bladder rupture in the setting of blunt or penetrating
external trauma. (AUA: Grade B)
• Clinicians should perform catheter drainage as treatment
for patients with uncomplicated extraperitoneal bladder
injuries. (AUA: Grade C)
• Surgeons should perform surgical repair in patients with
complicated extraperitoneal bladder injury.
(Recommendation; Evidence Strength: Grade C)
• Clinicians should perform urethral catheter drainage without
suprapubic (SP) cystostomy in patients following surgical
repair of bladder injuries. (Standard; Evidence Strength: Grade
B)
 Urethra Trauma
• Perform retrograde urethrography in patients with blood at the urethral
meatus after pelvic trauma. (AUA: Grade C)
• Establish prompt urinary drainage in patients with pelvic fracture associated
urethral injury. (AUA: Grade C)
• Surgeons may place suprapubic tubes (SPTs) in patients undergoing open
reduction internal fixation (ORIF) for pelvic fracture. (Expert Opinion)
• Clinicians may perform primary realignment (PR) in hemodynamically stable
patients with pelvic fracture associated urethral injury. (Option; Evidence
Strength: Grade C) Clinicians should not perform prolonged attempts at
endoscopic realignment in patients with pelvic fracture associated urethral
injury. (Clinical Principle)
• Clinicians should monitor patients for complications (e.g.,
stricture formation, erectile dysfunction, incontinence) for at
least one year following urethral injury. (AUA: Grade C)
• Surgeons should perform prompt surgical repair in patients
with uncomplicated penetrating trauma of the anterior
urethra. (Expert Opinion)
• Clinicians should establish prompt urinary drainage in patients
with straddle injury to the anterior urethra. (AUA: Grade C)
 Genital Trauma
• Clinicians must suspect penile fracture when a patient presents
with penile ecchymosis, swelling, cracking or snapping sound during
intercourse or manipulation and immediate detumescence. (AUA:
Grade B)
• Perform prompt surgical exploration and repair in patients with
acute signs and symptoms of penile fracture. (AUA: Grade B)
• Clinicians may perform ultrasound in patients with equivocal signs
and symptoms of penile fracture. (Expert Opinion)
• Perform evaluation for concomitant urethral injury in patients with
penile fracture or penetrating trauma who present with blood at
the urethral meatus, gross hematuria or inability to void. (AUA:
Grade B)
• Perform scrotal exploration and debridement with tunical closure
(when possible) or orchiectomy (when non-salvagable) in patients
with suspected testicular rupture. (AUA: Grade B)
• Perform exploration and limited debridement of non-viable tissue
in patients with extensive genital skin loss or injury from infection,
shearing injuries, or burns (thermal, chemical, electrical). (AUA:
Grade B)
• Perform prompt penile replantation in patients with traumatic
penile amputation, with the amputated appendage wrapped in
saline-soaked gauze, in a plastic bag and placed on ice during
transport. (Clinical Principle
• Clinicians should initiate ancillary psychological, interpersonal,
and/or reproductive counseling and therapy for patients with
genital trauma when loss of sexual, urinary, and/or
reproductive function is anticipated. (Expert Opinion)