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Injury of the Kidney, Ureter, and Bladder

50
Charles Acher and Suresh Agarwal

Including both blunt and penetrating trauma, renal injuries When CT imaging is bypassed in the hemodynamically
occur in 1.2 % of all trauma patients, and 1525 % of patients unstable patient who proceeds immediately to surgery, an
with pelvic fracture incur urologic injury. The American on-table one-shot intravenous pyelogram (IVP) should be
Association for the Surgery of Trauma (AAST) Injury performed by giving a 2 mg/kg IV contrast bolus followed
Criteria are used to characterize severity of renal and uro- by flat plate x-ray 10 min later. The main purpose of the IVP
logic injury (Tables 50.1, 50.2, 50.3, and 50.4). Repair of is to demonstrate two functioning kidneys and an intact
injury to the kidney, ureter, urethra, or bladder whenever drainage system. The presence of an injured solitary kidney
possible is essential to preserve long-term function. should prompt aggressive measures to spare nephrectomy
When a urologic injury is suspected in the context of pen- that would commit the patient to a lifetime of dialysis or
etrating trauma to the flank, abdomen, or low chest, imaging future transplantation.
of the upper urinary system is crucial for diagnosis. CT scan Angiography with selective embolization is a more
with IV contrast and delayed films at 10 min is the imaging recent modality to attempt nonoperative management.
modality of choice for hemodynamically stable patients. CT Indications for embolization include: active hemorrhage,
imaging should permit accurate injury staging based on the pseudoaneurysm, and vascular fistulas. Higher AAST grade
AAST criteria, which are highly predictive for operative renal injuries are associated with increased failure rates with
management. Medial hematoma, with or without extravasa- attempts at embolization, and embolization is three times
tion, on early films suggests renal vascular injury while that more likely to fail in penetrating trauma compared to blunt
on delayed films is usually indicative of renal pelvic injury or trauma. Additionally, failed embolization often ends in
proximal ureteral injury. Any part of the renal parenchyma nephrectomy.
that fails to show contrast on early-phase images suggests
arterial injury.
CT cystogram should be included in initial imaging when 50.1 Indications for Operative
bladder injury is suspected as a result of penetrating trauma Management
to the lower abdomen or pelvis. Indications include: gross
hematuria in the setting of blunt trauma, blunt trauma with Due to improvements in computed tomography imaging and
any degree of hematuria and a pelvic ring fracture, and pen- resuscitation methods, operative intervention for renal inju-
etrating trauma to the pelvis with hematuria. The sensitivity ries has been significantly reduced. Currently 36 % of pene-
and specificity of CT cystogram for bladder rupture are 95 trating and less than 5 % of blunt kidney injuries require
and 100 %, but should CT cystogram not show evidence of operative intervention In addition, about 30 % of penetrating
bladder injury despite clinical suspicion, retrograde cystog- and 45 % of blunt grade IV and V injuries are managed non-
raphy with full bladder distension should be performed and operatively. With the broadening criteria for nonoperative
post-drainage images obtained. Retrograde cystography management of renal injury, even in penetrating trauma
should be performed only in the absence of urethral injury. including some gunshots, the only absolute indications for
operative management are hemodynamic instability, expand-
ing or pulsatile perirenal hematoma, incomplete renal injury
C. Acher S. Agarwal (*) staging, renal pelvic injury, or non-visualization of the
Department of Surgery, University of Wisconsin School of
injured kidney on IVP. AAST stage IIII renal injuries are
Medicine and Public Health, 600 Highland Ave,
Madison, WI 53792, USA usually hemodynamically stable and are managed nonopera-
e-mail: agarwal@surgery.wisc.edu tively. Isolated stage IV renal injuries may be managed

Springer-Verlag Berlin Heidelberg 2017 387


G.C. Velmahos et al. (eds.), Penetrating Trauma, DOI 10.1007/978-3-662-49859-0_50
388 C. Acher and S. Agarwal

Table 50.1 Kidney injury scale


Gradea Type of injury Description of injury ICD-9 AIS-90
I Contusion Microscopic or gross hematuria, urologic studies normal 866.01 2
Hematoma Subcapsular, nonexpanding without parenchymal laceration 866.11 2
II Hematoma Nonexpanding perirenal hematoma confirmed to renal retroperitoneum 866.01 2
866.11
Laceration <1.0 cm parenchymal depth of renal cortex without urinary extravasation 866.02 2
866.12
III Laceration <1.0 cm parenchymal depth of renal cortex without collecting system rupture or 866.02 3
urinary extravasation
Laceration Parenchymal laceration extending through renal cortex, medulla, and collecting 866.12 4
system
IV
Vascular Main renal artery or vein injury with contained hemorrhage 4
V Laceration Completely shattered kidney 866.03 5
Vascular Avulsion of renal hilum which devascularizes kidney 866.13 5
a
Advance one grade for bilateral injuries up to grade III
Moore et al.

Table 50.2 Ureter injury scale


Gradea Type of injury Description of injury ICD-9 AIS-90
I Hematoma Contusion or hematoma without devascularization 867.2/867.3 2
II Laceration <50 % transection 867.2/867.3 2
III Laceration 50 % transection 867.2/867.3 3
IV Laceration Complete transection with < 2 cm devascularization 867.2/867.3 3
V Laceration Avulsion with > 2 cm of devascularization 867.2/867.3 3
a
Advance one grade for bilateral up to grade III
Moore et al.

Table 50.3 Bladder injury scale


Gradea Injury type Description of injury ICD-9 AIS-90
I Hematoma Contusion, intramural hematoma 867.0/867.1 2
Laceration Partial thickness 3
II Laceration Extraperitoneal bladder wall laceration <2 cm 867.0/867.1 4
III Laceration Extraperitoneal (2 cm) or intraperitoneal (<2 cm) bladder wall laceration 867.0/867.1 4
IV Laceration Intraperitoneal bladder wall laceration 2 cm 867.0/867.1 4
V Laceration Intraperitoneal or extraperitoneal bladder wall laceration extending into the bladder 867.0/867.1 4
neck or ureteral orifice (trigone)
a
Advance one grade for multiple lesions up to grade III
Moore et al.

Table 50.4 Urethra injury scale


Gradea Injury type Description of injury ICD-9 AIS-90
I Contusion Blood at urethral meatus; retrography normal 867.0/867.1 2
II Stretch injury Elongation of urethra without extravasation on urethrography 867.0/867.1 2
III Partial disruption Extravasation of urethrography contrast at injury site with visualization in the 867.0/867.1 2
bladder
IV Complete Extravasation of urethrography contrast at injury site without visualization in the 867.0/867.1 3
disruption bladder; <2 cm of urethra separation
V Complete Complete transaction with 2 cm urethral separation or extension into the prostate 867.0/867.1 4
disruption or vagina
a
Advance one grade for bilateral injuries up to grade III
Moore et al.
50 Injury of the Kidney, Ureter, and Bladder 389

nonoperatively when hemodynamically stable but must be


continually reassessed and re-imaged by CT scan at 48 h or
sooner if there is clinical decompensation. Superselective
embolization may be attempted for certain patients with
stage IV renal injuries who fail conservative management
due to persistent bleeding from segmental arteries. Stage V
renal injuries nearly always require operative intervention.
With these guidelines in mind however, renal injuries suf-
fered from penetrating trauma are almost always associated
with other injuries that dictate the decision to operate.
Almost all ureteral injuries require immediate operative
repair. In the event a ureteral injury is initially unrecognized
and consequently not repaired immediately, reconstruction
should be deferred for 36 months to allow inflammation to
resolve. All bladder neck and intraperitoneal bladder injuries
mandate repair, while most extraperitoneal bladder injuries
can be observed unless the patient undergoes laparotomy for
other injuries.

50.2 Operative Technique

Once committed to operative management, a standard trans-


abdominal midline incision is best for assessing renal injury
because both kidneys can be inspected through this approach
and midline incision allows access to the remainder of the Fig. 50.1 Carefully incise the retroperitoneum over the aorta at the
inferior mesenteric artery and extend superiorly to the ligament of
abdominal cavity. Abdominal packing, in typical trauma Treitz (dotted line)
laparotomy fashion, will help control bleeding. Attention
should first be turned to the destabilizing injury, urologic or
otherwise. are posterior and superior to the left renal vein on either side
of the aorta. Apply vessel loops to the renal arteries and
veins, but only occlude the vessels if severe bleeding must be
50.3 Vascular Control controlled (Fig. 50.2).
Renal occlusion time must be minimized to preserve func-
When the time comes to assess the bleeding kidney, vascular tion. Generally, arterial occlusion alone is enough to control
exposure is the first priority. Lift the transverse colon to the hemorrhage. If occlusion is necessary for more than 60 min
chest with a moist laparotomy pad and move the small bowel and patient stability permits, ice slush or cold renal perfusion
to the right in order to expose the retroperitoneum. Carefully solution may be used to cool the kidney to minimize warm
incise the retroperitoneum over the aorta at the inferior mes- ischemia time, thus prolonging ischemic tolerance.
enteric artery and extend superiorly to the ligament of Treitz Anatomic variation of the renal vasculature is not uncom-
(Fig. 50.1). The left renal vein can be identified where it mon with a high frequency of multiple renal arteries and
crosses the aorta anteriorly, noting that the vein rarely crosses veins making vascular control potentially difficult. Most
posteriorly and when it does it may be duplicated. Sometimes notable is the prevalence of renal arteries originating below
a large retroperitoneal hematoma distorts the anatomy. In the IMA, multiple right renal veins, and less frequently ret-
this case, make the incision just medial to the inferior mesen- roaortic or circumaortic left renal vein. When bleeding is not
teric vein and proceed to identify the left renal vein. Wrap a controlled with occlusion of standard renal vessels, anatomic
vessel loop around the vein without occluding it, unless variants must be considered. When more urgent hemostasis
bleeding from this vessel is heavy. The remaining renal ves- is required or if the source of bleeding is unclear, proximal
sels should be identified in order: left renal artery, right renal control may be gained by transiently occluding the aorta at
vein, and right renal artery. The left and right renal arteries the gastroesophageal junction or in the chest.
390 C. Acher and S. Agarwal

damage control is the priority. The removed kidney may be


reimplanted up to 48 h later if it is appropriately preserved.
Complete renal vein disruption may result in nephrectomy
unless it is the left main renal vein at its origin with the vena
cava, in which case the vein may be ligated because the left kid-
ney has collateral drainage of via the gonadal and adrenal veins.

50.5 Renal Exposure

Attention may be turned to renal exposure once renal vascu-


lar identification and control have been established. These
techniques may also be applied to renal vascular exposure,
especially in case of a large retroperitoneal hematoma.
Incise the retroperitoneum lateral to the colon at the white
line of Toldt and reflect medially. On the left side, division
of the splenorenal ligament followed by medial reflection of
the spleen and colon will completely expose the left kidney
and associated vasculature. When exploring the right side,
Fig. 50.2 Apply vessel loops to the renal arteries and veins but only incise the hepatic flexure in addition to the retroperitoneum
occlude the vessels if severe bleeding must be controlled lateral to the colon. Once the duodenum and pancreatic head
are mobilized medially, the right renal artery and vein can be
identified along with the origin of the left renal vein. Gerotas
50.4 Vascular Repair fascia may be incised along its lateral aspect for complete
renal exposure. Preserve as much of the renal capsule as pos-
Vascular injuries to renal vessels are rare in the context of sible as it will likely be used for closure of the reconstruction.
trauma and their repair is successful less than half of the
time. Renal artery salvage should only be attempted in the
case of a solitary kidney or bilateral injuries and if the injury 50.6 Partial Nephrectomy
is less than 6 h old.
Arterial and venous injuries should be repaired with run- Partial nephrectomy is required when either pole of the kid-
ning or interrupted vascular sutures such a 5-0 or 6-0 Prolene. ney is severely damaged. Generously debride nonviable
Segmental veins can be ligated given the extensive collateral renal tissue down to actively bleeding parenchyma noting
venous drainage in the kidney. On the other hand, ligation of that only 30 % of a single normal kidney is needed to avoid
segmental renal arteries is problematic because they are end- dialysis. Suture ligate individual bleeding vessels with 4-0
organ vessels. If their sacrifice is necessary, distal paren- chromic sutures. Do not use nonabsorbable suture material
chyma will become ischemic and may infarct, and subsequent in the parenchyma or collecting system. Parenchymal hemo-
evaluation and debridement of infarcted parenchyma must stasis may be achieved with direct pressure. Alternatively, a
follow. Keith needle with absorbable suture can be passed through
Complete renal artery disruption requires debridement the full thickness of the parenchyma, from capsule to capsule
and excision of damaged vessel tissue followed by end-to- and back, with supporting pledgets to help achieve hemosta-
end, tension-free anastomosis. Use saphenous vein or inter- sis. This should not be attempted if the collecting system is
nal iliac artery graft to augment repair of arterial defects involved. Diffuse oozing can be managed with direct com-
greater than 2 cm that may result in severe narrowing with- pression while electrocauterizing the denuded surface.
out interposition graft. Avoid synthetic graft material due to Close the collecting system with a watertight running 4-0
the contaminated nature of the trauma laparotomy and the chromic suture. Integrity of the closure may be tested by
increased risk of infection with synthetic material. injecting methylene blue dye into the renal pelvis while com-
Renal autotransplantation may be considered if the renal pressing the ureter and inspecting for extravasation.
artery pedicle is severely injured but the kidney itself is sal- Thrombin-soaked gelfoam may be placed between cut
vageable, especially if the patient has multiple injuries and parenchymal edges to improve hemostasis. Gently pull the
50 Injury of the Kidney, Ureter, and Bladder 391

b c

Fig. 50.3 The injured kidney is debrided sparsely (a). Gently pull the capsule directly over the defect and secure (b) after closure of the collecting
system (c). If sufficient capsule is not available, an omental pedicle flap may be used to cover the defect

capsule directly over the defect and secure. If sufficient the extensively repaired kidney. The kidney, once repaired,
capsule is unavailable, an omental pedicle flap may be used should be placed back within Gerotas fascia but the fascia
to cover the defect (Fig. 50.3). should not be re-approximated.
Following partial nephrectomy or renorrhaphy, a retro-
peritoneal drain should be placed without suction, to decrease
50.7 Renorrhaphy likelihood of a urine leak, and left in place for 23 days or lon-
ger if output is high or creatinine from the drainage is elevated.
Renorrhaphy is necessary for middle kidney damage. As for
partial nephrectomy, debride nonviable tissue to bleeding
parenchyma. Ligate vessels and close the collecting system 50.8 Nephrectomy
with 4-0 chromic suture as above. Approximate parenchy-
mal edges and secure with interrupted 3-0 absorbable sutures When the kidney is shattered or in the context of damage
anchored to the capsule for support, tied over an absorbable control laparotomy, nephrectomy may be inevitable. Perform
gelatin bolster. As for partial nephrectomy, an omental ped- ligation of the renal artery first with long-lasting absorbable
icle flap can be used to close the defect if capsule quantity suture. Double suture ligation is necessary only in the pres-
is inadequate. Similarly, absorbable mesh can help stabilize ence of severe atherosclerosis. Follow with ligation of the
392 C. Acher and S. Agarwal

renal vein. Complete renal isolation by ligating the ureter in contrast cystography prior to removal and the double-J stand
two places close to the bladder. should be removed 46 weeks after repair.

50.9 Ureteral Repair 50.10 Ureteroureterostomy

A high index of suspicion is required to diagnose ureteral Middle and upper ureteral injuries are best repaired with ure-
injury. Although CT scan, IVP, or retrograde pyelography teroureterostomy. Mobilization of proximal and distal seg-
may diagnose this injury, intraoperative diagnosis via ments should be performed gingerly to avoid disrupting
direct inspection with or without intravenous or intra-ure- vascular supply that runs along the ureter originating from
teral injection of indigo carmine or methylene blue to con- the renal vessels or superior vesicular vessels. As above,
firm the integrity of the collecting system may be required debride nonviable tissue to healthy bleeding tissue and spat-
to diagnose ureteral disruption. Ureteral blast injury from ulate the ends. Tack the apices of each spatulation through
nearby intra-abdominal gunshot is more difficult to diag- the opposite ureter with 4-0 or 5-0 absorbable suture, ensur-
nose because the delayed necrosis that occurs as a result of ing that knots are exterior. Clamps applied to the tails of
intimal disruption is often not apparent immediately, these sutures will help stabilize the field to minimize han-
although sometimes this may appear as bruising on the dling. Insert a double-J stent and complete the anastomosis
ureteral wall. with interrupted 4-0 or 5-0 absorbable suture, anterior side
Immediate repair is needed when ureteral injury or first and posterior side second (Fig. 50.4). Consider an omen-
devascularization is identified. Debride nonviable tissue to tal flap if contamination is high or infection likely. Drain ret-
healthy bleeding tissue and perform a watertight tension- roperitoneally without suction.
free repair. During damage control laparotomy, tying off If a tension-free anastomosis cannot be achieved through
the injured ureteral segment with a long silk suture is pre- direct re-approximation of proximal and distal segments,
ferred until the patient is stable enough for delayed ure- then end-to-side transureteroureterostomy should be consid-
teral reconstruction, usually several months later. Urinary ered. The proximal segment of the injured ureter can be
diversion via percutaneous nephrostomy drain can be brought through the mesentery either above or below the
undertaken postoperatively. Alternatively, drainage of the IMA (depending on degree of loss), being mindful of the
proximal end of the disrupted ureter with a ureteral stent or potential for ureteral devascularization. Spatulate the end of
pediatric feeding tube brought out through the skin with the mobilized ureter before incising the contralateral ureter
spatulated ureteral edges sewn to skin, forming a stoma, is with a 2 cm longitudinal medial ureterotomy. Tack the apices
another option. of the spatulated end to the inferior and superior poles of the
Partial ureteral transection may be closed primarily ureterotomy with a 4-0 or 5-0 absorbable suture. Start the
with interrupted 4-0 or 5-0 absorbable monofilament stitch from the ureterotomy, and then bring through the spat-
suture (PDS), unless the injury is caused by gunshot, in ulated end. Insert a double-J stent and close the anastomosis
which case more extensive debridement plus ureteroure- with 4-0 or 5-0 absorbable interrupted suture. Apply an
terostomy is recommended. Handling of the ureters dur- omental flap as needed and always insert a retroperitoneal
ing mobilization should always be minimized as blood drain.
supply is easily disrupted. Approximate the lumen with
absorbable 4-0 or 5-0 monofilament suture and place a
double-J stent when the defect is greater than 50 % of the 50.11 Ureteroneocystostomy
lumen and complete the repair with interrupted sutures as
above. Remove the stent after 6 weeks. A guidewire will Distal ureteral injuries in the stable patient are best repaired
facilitate stent placement when placed through a side hole with ureteroneocystostomy. Debride the proximal ureteral
of the double-J stent, directing one end of the stent upward end to healthy, bleeding tissue and spatulate the end. A tun-
to the renal pelvis and the other end to the bladder. Use an nel should be created for its insertion superior and medial to
omental flap to isolate the segment if the repair is tenuous the original distal ureteral opening at a length of three times
or if significant contamination is present in the peritoneal the ureteral diameter. Anastomose the ureter to the interior
cavity. A retroperitoneal gravity drain is strongly encour- aspect of the bladder using 5-0 absorbable sutures and place
aged as it will permit early diagnosis of urinary leakage an internal stent (Fig. 50.5). Perform an antireflux procedure
should it occur and will help small anastomotic gaps heal. at ureterocystostomy with 4-0 nonabsorbable monofilament.
Regardless of type of ureteral repair, bladder decompres- Ligation of the original distal ureteral stump is needed only
sion should be continued for 7 days after repair with a if reflux is suspected.
50 Injury of the Kidney, Ureter, and Bladder 393

a b

Fig. 50.4 In ureteroureterostomy, insert a double-J stent (a, b) and complete the anastomosis with interrupted 4-0 or 5-0 absorbable suture, ante-
rior side first and posterior side second (a). The renal artery is typically reimplanted end to end to the hypogastric artery or end to side to the
external or common iliac artery. Depending on the available anatomy, the end-to-end operation is usually performed in the contralateral iliac fossa,
whereas the ipsilateral iliac fossa is used for end-to-side operations. The iliac fossa should be exposed by reflecting the peritoneum superiorly and
medially so that the common iliac artery and bladder can be visualized. A self-retaining ring retractor will help maintain exposure; however, retrac-
tor blades must be placed with caution to the lateral femoral cutaneous nerve and inferior common iliac artery. Lymphatic tissue must be meticu-
lously ligated to avoid postoperative lymphocele, because this region is rich in lymphatic channels

Fig. 50.5 In
ureterocystostomy,
anastomose the tunneled
ureter to the interior aspect of
the bladder using 5-0
absorbable sutures and place
an internal stent (ac)
394 C. Acher and S. Agarwal

Other alternatives to achieve a tension-free anastomosis The 3-0 chromic sutures are then used to close the bladder
include ureteral reimplantation with psoas hitch and the muscle over the ureter.
Boari flap, both of which can provide additional distal length
when needed. Both are beyond the scope of this discussion
and are well described in the texts referenced at the end of 50.13 Bladder Repair
this chapter.
While bladder injury is most commonly caused by blunt
trauma, 1435 % is due to penetrating trauma. Additionally
50.12 Autotransplantation 39 % of pelvic fractures have associated bladder injury
and around 65 % of bladder injuries are extraperitoneal.
Renal autotransplantation is rarely the best option for the Extraperitoneal injuries can be managed with catheter
renal trauma patient, but in instances of a damaged solitary drainage for 10 days with a cystogram prior to removing
kidney or renal artery or collecting system avulsion in the the catheter. Contraindications to nonoperative management
setting of damage control surgery, renal autotransplantation include: urinary infection, pelvic fractures requiring internal
may potentially save the patient from a lifetime of dialysis or fixation, and bladder neck injury. Repair of intraperitoneal
allograft. Once the choice has been made to proceed with bladder injuries is usually achieved through primary closure of
autotransplantation, the kidney should be removed rapidly the defect and placement of a urethral catheter. A transperito-
with minimal surgical manipulation. Maximize length of neal cystotomy should be made to visualize the entire lumen,
renal vessels and ureter. The removed kidney should be as unrecognized extraperitoneal ruptures are not uncommon
flushed immediately with cold intracellular electrolyte solu- and should be repaired at the time of intraperitoneal bladder
tion (500 mL of Collins or University of Wisconsin solution) repair. If bleeding from pelvic hematoma is encountered, as
intra-arterially and submerged in a basin of ice slush saline it frequently is in the context of pelvic fractures, be prepared
solution until transfer to an appropriate cooler if the trans- with sponges and perform suture ligations as needed.
plant will take place at another operation. The ureteral orifices should be identified, and after IV
Dissect the external iliac vein carefully from its origin to indigo carmine injection, blue urine should be observed
the femoral junction. Place vascular clamps proximally and effluxing from each opening. If the injury is close to or involv-
distally on the external iliac vein and complete a narrow ellip- ing the ureteral opening, a ureteral stent should be placed.
tical venotomy on the veins anterolateral aspect. If the hypo- Debridement of damaged bladder tissue is usually mini-
gastric artery is to receive the renal artery, it should be occluded mal in light of its extensive blood supply. The intraperitoneal
proximally and ligated and divided distally. If the external iliac bladder injury can be closed with running 3-0 absorbable
artery or common iliac artery is to be used, occlude the com- suture in the mucosa and running 2-0 absorbable suture in
mon iliac, external iliac, and hypogastric arteries with vascular the muscularis propria. The peritoneum should be closed
clamps before making the arteriotomy. Inject heparin into the with a separate 3-0 running absorbable suture.
recipient vessels and bring the autotransplant into the field.
The end-to-side venous anastomosis is performed first
using continuous 5-0 vascular suture. The arterial anastomo- 50.14 Bladder Neck Repair
sis is performed second using interrupted 6-0 vascular suture.
At this point, the vascular clamps should be removed to Urethral injuries are uncommon in penetrating trauma and
assess for leaks and repairs performed as needed. present with blood at the urethral meatus. Catheter place-
Finally the ureteroneocystostomy should be per- ment should be avoided because it can turn an incomplete
formed. Using the shortest possible length of ureter to injury into a more extensive disruption. Such lesions are
avoid kinking and ischemia, spatulate the distal end of the diagnosed with retrograde urethrography, and posterior inju-
donor ureter. Make a 3 cm incision at the posterolateral ries should be realigned using lower midline incision and
aspect of the bladder and incise down the expose the passage of a catheter, whereas anterior injuries should
mucosa. Undermine the muscular layer of the bladder undergo surgical repair. Bladder neck injuries are notori-
slightly and make a small opening into the bladder ously difficult to repair, but repair should be attempted to
mucosa at the inferior pole of the incision. Complete a preserve continence. The injury should be exposed through a
mucosa-to-mucosa anastomosis between the ureter and cystotomy at the dome and all tears closed with absorbable
bladder using 4-0 chromic sutures (continuous or inter- sutures. Placement of Foley catheter and suprapubic tube, as
rupted). The distal-most end of the anastomosis should be described above, is recommended. Vaginal and other genital
anchored through the full thickness of the bladder wall. lacerations, if present, should be repaired at the same time.
50 Injury of the Kidney, Ureter, and Bladder 395

50.14.1 Postoperative Management


Always use a retroperitoneal drain following
Patients with renal injuries who are managed nonoperatively reconstruction without suction.
and those with grade IV injuries with urinary extravasation Always use absorbable sutures in the genitourinary
may need follow-up imaging in 4872 h to evaluate for tract.
ongoing extravasation, as this could require operative explo- Operative repair is standard for intraperitoneal
ration. If a peri-nephric fluid collection is drained and tests bladder injury, whereas nonoperative management
are positive for creatinine, the drain should be left in place with catheter drainage is standard for most extra-
until the collection resolves and leak is not demonstrated. peritoneal bladder injuries.
Retroperitoneal drains placed during surgery should not be
placed to suction postoperatively and should be removed
within 48 h unless a urine leak is demonstrated.
For urethral injuries Foley catheters should remain in Recommended Reading
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