Injury of the Kidney, Ureter, and Bladder
50
Charles Acher and Suresh Agarwal
Including both blunt and penetrating trauma, renal injuries
occur in 1.2 % of all trauma patients, and 1525 % of patients
with pelvic fracture incur urologic injury. The American
Association for the Surgery of Trauma (AAST) Injury
Criteria are used to characterize severity of renal and uro-
logic injury (Tables 50.1, 50.2, 50.3, and 50.4). Repair of
injury to the kidney, ureter, urethra, or bladder whenever
possible is essential to preserve long-term function.
When a urologic injury is suspected in the context of pen-
etrating trauma to the flank, abdomen, or low chest, imaging
of the upper urinary system is crucial for diagnosis. CT scan
with IV contrast and delayed films at 10 min is the imaging
modality of choice for hemodynamically stable patients. CT
imaging should permit accurate injury staging based on the
AAST criteria, which are highly predictive for operative
management. Medial hematoma, with or without extravasa-
tion, on early films suggests renal vascular injury while that
on delayed films is usually indicative of renal pelvic injury or
proximal ureteral injury. Any part of the renal parenchyma
that fails to show contrast on early-phase images suggests
arterial injury.
CT cystogram should be included in initial imaging when
bladder injury is suspected as a result of penetrating trauma
to the lower abdomen or pelvis. Indications include: gross
hematuria in the setting of blunt trauma, blunt trauma with
any degree of hematuria and a pelvic ring fracture, and pen-
etrating trauma to the pelvis with hematuria. The sensitivity
and specificity of CT cystogram for bladder rupture are 95
and 100 %, but should CT cystogram not show evidence of
bladder injury despite clinical suspicion, retrograde cystog-
raphy with full bladder distension should be performed and
post-drainage images obtained. Retrograde cystography
should be performed only in the absence of urethral injury.
C. Acher S. Agarwal (*)
Department of Surgery, University of Wisconsin School of
Medicine and Public Health, 600 Highland Ave,
Madison, WI 53792, USA
e-mail: agarwal@surgery.wisc.edu
Springer-Verlag Berlin Heidelberg 2017
G.C. Velmahos et al. (eds.), Penetrating Trauma, DOI 10.1007/978-3-662-49859-0_50
When CT imaging is bypassed in the hemodynamically
unstable patient who proceeds immediately to surgery, an
on-table one-shot intravenous pyelogram (IVP) should be
performed by giving a 2 mg/kg IV contrast bolus followed
by flat plate x-ray 10 min later. The main purpose of the IVP
is to demonstrate two functioning kidneys and an intact
drainage system. The presence of an injured solitary kidney
should prompt aggressive measures to spare nephrectomy
that would commit the patient to a lifetime of dialysis or
future transplantation.
Angiography with selective embolization is a more
recent modality to attempt nonoperative management.
Indications for embolization include: active hemorrhage,
pseudoaneurysm, and vascular fistulas. Higher AAST grade
renal injuries are associated with increased failure rates with
attempts at embolization, and embolization is three times
more likely to fail in penetrating trauma compared to blunt
trauma. Additionally, failed embolization often ends in
nephrectomy.
50.1 Indications for Operative
Management
Due to improvements in computed tomography imaging and
resuscitation methods, operative intervention for renal inju-
ries has been significantly reduced. Currently 36 % of pene-
trating and less than 5 % of blunt kidney injuries require
operative intervention In addition, about 30 % of penetrating
and 45 % of blunt grade IV and V injuries are managed non-
operatively. With the broadening criteria for nonoperative
management of renal injury, even in penetrating trauma
including some gunshots, the only absolute indications for
operative management are hemodynamic instability, expand-
ing or pulsatile perirenal hematoma, incomplete renal injury
staging, renal pelvic injury, or non-visualization of the
injured kidney on IVP. AAST stage IIII renal injuries are
usually hemodynamically stable and are managed nonopera-
tively. Isolated stage IV renal injuries may be managed
387
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
abdominal cavity. Abdominal packing, in typical trauma
laparotomy fashion, will help control bleeding. Attention
should first be turned to the destabilizing injury, urologic or
otherwise.
50.3 Vascular Control
When the time comes to assess the bleeding kidney, vascular
exposure is the first priority. Lift the transverse colon to the
chest with a moist laparotomy pad and move the small bowel
to the right in order to expose the retroperitoneum. Carefully
incise the retroperitoneum over the aorta at the inferior mes-
enteric artery and extend superiorly to the ligament of Treitz
(Fig. 50.1). The left renal vein can be identified where it
crosses the aorta anteriorly, noting that the vein rarely crosses
posteriorly and when it does it may be duplicated. Sometimes
a large retroperitoneal hematoma distorts the anatomy. In
this case, make the incision just medial to the inferior mesen-
teric vein and proceed to identify the left renal vein. Wrap a
vessel loop around the vein without occluding it, unless
bleeding from this vessel is heavy. The remaining renal ves-
sels should be identified in order: left renal artery, right renal
vein, and right renal artery. The left and right renal arteries
Fig. 50.1 Carefully incise the retroperitoneum over the aorta at the
inferior mesenteric artery and extend superiorly to the ligament of
Treitz (dotted line)
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
controlled (Fig. 50.2).
Renal occlusion time must be minimized to preserve func-
tion. Generally, arterial occlusion alone is enough to control
hemorrhage. If occlusion is necessary for more than 60 min
and patient stability permits, ice slush or cold renal perfusion
solution may be used to cool the kidney to minimize warm
ischemia time, thus prolonging ischemic tolerance.
Anatomic variation of the renal vasculature is not uncom-
mon with a high frequency of multiple renal arteries and
veins making vascular control potentially difficult. Most
notable is the prevalence of renal arteries originating below
the IMA, multiple right renal veins, and less frequently ret-
roaortic or circumaortic left renal vein. When bleeding is not
controlled with occlusion of standard renal vessels, anatomic
variants must be considered. When more urgent hemostasis
is required or if the source of bleeding is unclear, proximal
control may be gained by transiently occluding the aorta at
the gastroesophageal junction or in the chest.
390
Fig. 50.2 Apply vessel loops to the renal arteries and veins but only
occlude the vessels if severe bleeding must be controlled
50.4 Vascular Repair
Vascular injuries to renal vessels are rare in the context of
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
is less than 6 h old.
Arterial and venous injuries should be repaired with run-
ning or interrupted vascular sutures such a 5-0 or 6-0 Prolene.
Segmental veins can be ligated given the extensive collateral
venous drainage in the kidney. On the other hand, ligation of
segmental renal arteries is problematic because they are end-
organ vessels. If their sacrifice is necessary, distal paren-
chyma will become ischemic and may infarct, and subsequent
evaluation and debridement of infarcted parenchyma must
follow.
Complete renal artery disruption requires debridement
and excision of damaged vessel tissue followed by end-to-
end, tension-free anastomosis. Use saphenous vein or inter-
nal iliac artery graft to augment repair of arterial defects
greater than 2 cm that may result in severe narrowing with-
out interposition graft. Avoid synthetic graft material due to
the contaminated nature of the trauma laparotomy and the
increased risk of infection with synthetic material.
Renal autotransplantation may be considered if the renal
artery pedicle is severely injured but the kidney itself is sal-
vageable, especially if the patient has multiple injuries and
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,
incise the hepatic flexure in addition to the retroperitoneum
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
fascia may be incised along its lateral aspect for complete
renal exposure. Preserve as much of the renal capsule as pos-
sible as it will likely be used for closure of the reconstruction.
50.6 Partial Nephrectomy
Partial nephrectomy is required when either pole of the kid-
ney is severely damaged. Generously debride nonviable
renal tissue down to actively bleeding parenchyma noting
that only 30 % of a single normal kidney is needed to avoid
dialysis. Suture ligate individual bleeding vessels with 4-0
chromic sutures. Do not use nonabsorbable suture material
in the parenchyma or collecting system. Parenchymal hemo-
stasis may be achieved with direct pressure. Alternatively, a
Keith needle with absorbable suture can be passed through
the full thickness of the parenchyma, from capsule to capsule
and back, with supporting pledgets to help achieve hemosta-
sis. This should not be attempted if the collecting system is
involved. Diffuse oozing can be managed with direct com-
pression while electrocauterizing the denuded surface.
Close the collecting system with a watertight running 4-0
chromic suture. Integrity of the closure may be tested by
injecting methylene blue dye into the renal pelvis while com-
pressing the ureter and inspecting for extravasation.
Thrombin-soaked gelfoam may be placed between cut
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
capsule is unavailable, an omental pedicle flap may be used
to cover the defect (Fig. 50.3).
50.7 Renorrhaphy
Renorrhaphy is necessary for middle kidney damage. As for
partial nephrectomy, debride nonviable tissue to bleeding
parenchyma. Ligate vessels and close the collecting system
with 4-0 chromic suture as above. Approximate parenchy-
mal edges and secure with interrupted 3-0 absorbable sutures
anchored to the capsule for support, tied over an absorbable
gelatin bolster. As for partial nephrectomy, an omental ped-
icle flap can be used to close the defect if capsule quantity
is inadequate. Similarly, absorbable mesh can help stabilize
the extensively repaired kidney. The kidney, once repaired,
should be placed back within Gerotas fascia but the fascia
should not be re-approximated.
Following partial nephrectomy or renorrhaphy, a retro-
peritoneal drain should be placed without suction, to decrease
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.
50.8 Nephrectomy
When the kidney is shattered or in the context of damage
control laparotomy, nephrectomy may be inevitable. Perform
ligation of the renal artery first with long-lasting absorbable
suture. Double suture ligation is necessary only in the pres-
ence of severe atherosclerosis. Follow with ligation of the
392
renal vein. Complete renal isolation by ligating the ureter in
two places close to the bladder.
50.9 Ureteral Repair
A high index of suspicion is required to diagnose ureteral
injury. Although CT scan, IVP, or retrograde pyelography
may diagnose this injury, intraoperative diagnosis via
direct inspection with or without intravenous or intra-ure-
teral injection of indigo carmine or methylene blue to con-
firm the integrity of the collecting system may be required
to diagnose ureteral disruption. Ureteral blast injury from
nearby intra-abdominal gunshot is more difficult to diag-
nose because the delayed necrosis that occurs as a result of
intimal disruption is often not apparent immediately,
although sometimes this may appear as bruising on the
ureteral wall.
Immediate repair is needed when ureteral injury or
devascularization is identified. Debride nonviable tissue to
healthy bleeding tissue and perform a watertight tension-
free repair. During damage control laparotomy, tying off
the injured ureteral segment with a long silk suture is pre-
ferred until the patient is stable enough for delayed ure-
teral reconstruction, usually several months later. Urinary
diversion via percutaneous nephrostomy drain can be
undertaken postoperatively. Alternatively, drainage of the
proximal end of the disrupted ureter with a ureteral stent or
pediatric feeding tube brought out through the skin with
spatulated ureteral edges sewn to skin, forming a stoma, is
another option.
Partial ureteral transection may be closed primarily
with interrupted 4-0 or 5-0 absorbable monofilament
suture (PDS), unless the injury is caused by gunshot, in
which case more extensive debridement plus ureteroure-
terostomy is recommended. Handling of the ureters dur-
ing mobilization should always be minimized as blood
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
lumen and complete the repair with interrupted sutures as
above. Remove the stent after 6 weeks. A guidewire will
facilitate stent placement when placed through a side hole
of the double-J stent, directing one end of the stent upward
to the renal pelvis and the other end to the bladder. Use an
omental flap to isolate the segment if the repair is tenuous
or if significant contamination is present in the peritoneal
cavity. A retroperitoneal gravity drain is strongly encour-
aged as it will permit early diagnosis of urinary leakage
should it occur and will help small anastomotic gaps heal.
Regardless of type of ureteral repair, bladder decompres-
sion should be continued for 7 days after repair with a
C. Acher and S. Agarwal
contrast cystography prior to removal and the double-J stand
should be removed 46 weeks after repair.
50.10 Ureteroureterostomy
Middle and upper ureteral injuries are best repaired with ure-
teroureterostomy. Mobilization of proximal and distal seg-
ments should be performed gingerly to avoid disrupting
vascular supply that runs along the ureter originating from
the renal vessels or superior vesicular vessels. As above,
debride nonviable tissue to healthy bleeding tissue and spat-
ulate the ends. Tack the apices of each spatulation through
the opposite ureter with 4-0 or 5-0 absorbable suture, ensur-
ing that knots are exterior. Clamps applied to the tails of
these sutures will help stabilize the field to minimize han-
dling. Insert a double-J stent and complete the anastomosis
with interrupted 4-0 or 5-0 absorbable suture, anterior side
first and posterior side second (Fig. 50.4). Consider an omen-
tal flap if contamination is high or infection likely. Drain ret-
roperitoneally without suction.
If a tension-free anastomosis cannot be achieved through
direct re-approximation of proximal and distal segments,
then end-to-side transureteroureterostomy should be consid-
ered. The proximal segment of the injured ureter can be
brought through the mesentery either above or below the
IMA (depending on degree of loss), being mindful of the
potential for ureteral devascularization. Spatulate the end of
the mobilized ureter before incising the contralateral ureter
with a 2 cm longitudinal medial ureterotomy. Tack the apices
of the spatulated end to the inferior and superior poles of the
ureterotomy with a 4-0 or 5-0 absorbable suture. Start the
stitch from the ureterotomy, and then bring through the spat-
ulated end. Insert a double-J stent and close the anastomosis
with 4-0 or 5-0 absorbable interrupted suture. Apply an
omental flap as needed and always insert a retroperitoneal
drain.
50.11 Ureteroneocystostomy
Distal ureteral injuries in the stable patient are best repaired
with ureteroneocystostomy. Debride the proximal ureteral
end to healthy, bleeding tissue and spatulate the end. A tun-
nel should be created for its insertion superior and medial to
the original distal ureteral opening at a length of three times
the ureteral diameter. Anastomose the ureter to the interior
aspect of the bladder using 5-0 absorbable sutures and place
an internal stent (Fig. 50.5). Perform an antireflux procedure
at ureterocystostomy with 4-0 nonabsorbable monofilament.
Ligation of the original distal ureteral stump is needed only
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
Other alternatives to achieve a tension-free anastomosis
include ureteral reimplantation with psoas hitch and the
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
this chapter.
50.12 Autotransplantation
Renal autotransplantation is rarely the best option for the
renal trauma patient, but in instances of a damaged solitary
kidney or renal artery or collecting system avulsion in the
setting of damage control surgery, renal autotransplantation
may potentially save the patient from a lifetime of dialysis or
allograft. Once the choice has been made to proceed with
autotransplantation, the kidney should be removed rapidly
with minimal surgical manipulation. Maximize length of
renal vessels and ureter. The removed kidney should be
flushed immediately with cold intracellular electrolyte solu-
tion (500 mL of Collins or University of Wisconsin solution)
intra-arterially and submerged in a basin of ice slush saline
solution until transfer to an appropriate cooler if the trans-
plant will take place at another operation.
Dissect the external iliac vein carefully from its origin to
the femoral junction. Place vascular clamps proximally and
distally on the external iliac vein and complete a narrow ellip-
tical venotomy on the veins anterolateral aspect. If the hypo-
gastric artery is to receive the renal artery, it should be occluded
proximally and ligated and divided distally. If the external iliac
artery or common iliac artery is to be used, occlude the com-
mon iliac, external iliac, and hypogastric arteries with vascular
clamps before making the arteriotomy. Inject heparin into the
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-
sis is performed second using interrupted 6-0 vascular suture.
At this point, the vascular clamps should be removed to
assess for leaks and repairs performed as needed.
Finally the ureteroneocystostomy should be per-
formed. Using the shortest possible length of ureter to
avoid kinking and ischemia, spatulate the distal end of the
donor ureter. Make a 3 cm incision at the posterolateral
aspect of the bladder and incise down the expose the
mucosa. Undermine the muscular layer of the bladder
slightly and make a small opening into the bladder
mucosa at the inferior pole of the incision. Complete a
mucosa-to-mucosa anastomosis between the ureter and
bladder using 4-0 chromic sutures (continuous or inter-
rupted). The distal-most end of the anastomosis should be
anchored through the full thickness of the bladder wall.
C. Acher and S. Agarwal
The 3-0 chromic sutures are then used to close the bladder
muscle over the ureter.
50.13 Bladder Repair
While bladder injury is most commonly caused by blunt
trauma, 1435 % is due to penetrating trauma. Additionally
39 % of pelvic fractures have associated bladder injury
and around 65 % of bladder injuries are extraperitoneal.
Extraperitoneal injuries can be managed with catheter
drainage for 10 days with a cystogram prior to removing
the catheter. Contraindications to nonoperative management
include: urinary infection, pelvic fractures requiring internal
fixation, and bladder neck injury. Repair of intraperitoneal
bladder injuries is usually achieved through primary closure of
the defect and placement of a urethral catheter. A transperito-
neal cystotomy should be made to visualize the entire lumen,
as unrecognized extraperitoneal ruptures are not uncommon
and should be repaired at the time of intraperitoneal bladder
repair. If bleeding from pelvic hematoma is encountered, as
it frequently is in the context of pelvic fractures, be prepared
with sponges and perform suture ligations as needed.
The ureteral orifices should be identified, and after IV
indigo carmine injection, blue urine should be observed
effluxing from each opening. If the injury is close to or involv-
ing the ureteral opening, a ureteral stent should be placed.
Debridement of damaged bladder tissue is usually mini-
mal in light of its extensive blood supply. The intraperitoneal
bladder injury can be closed with running 3-0 absorbable
suture in the mucosa and running 2-0 absorbable suture in
the muscularis propria. The peritoneum should be closed
with a separate 3-0 running absorbable suture.
50.14 Bladder Neck Repair
Urethral injuries are uncommon in penetrating trauma and
present with blood at the urethral meatus. Catheter place-
ment should be avoided because it can turn an incomplete
injury into a more extensive disruption. Such lesions are
diagnosed with retrograde urethrography, and posterior inju-
ries should be realigned using lower midline incision and
passage of a catheter, whereas anterior injuries should
undergo surgical repair. Bladder neck injuries are notori-
ously difficult to repair, but repair should be attempted to
preserve continence. The injury should be exposed through a
cystotomy at the dome and all tears closed with absorbable
sutures. Placement of Foley catheter and suprapubic tube, as
described above, is recommended. Vaginal and other genital
lacerations, if present, should be repaired at the same time.
50 Injury of the Kidney, Ureter, and Bladder
50.14.1 Postoperative Management
Patients with renal injuries who are managed nonoperatively
and those with grade IV injuries with urinary extravasation
may need follow-up imaging in 4872 h to evaluate for
ongoing extravasation, as this could require operative explo-
ration. If a peri-nephric fluid collection is drained and tests
are positive for creatinine, the drain should be left in place
until the collection resolves and leak is not demonstrated.
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
place for 3 weeks with a voiding cystourethrogram prior to
removal.
Abdominal and pelvic trauma can cause kidney, ureteral,
urethral, and bladder injuries that, even if recognized and
treated, may result in long-term urologic dysfunction or
renal insufficiency. Grade of renal injury by AAST criteria is
predictive of decrease in renal function. Grade III, IV, and V
injuries have decreases in renal function of 1 %, 30 %, and
65 %, respectively, in the injured kidney (Taison 2003).
Important Points
On-table one-shot IVP should be used to prove the
presence of two functional kidneys and an intact
collecting system when CT scan is not possible.
Renal vascular exposure and control should be
addressed first, occluding vessels only as needed
and only for less than 30 min.
Partial nephrectomy is indicated for polar injuries,
renorrhaphy for middle kidney injuries, and
nephrectomy for shattered kidneys and unsalvage-
able vascular injuries.
During damage control laparotomy, nephrectomy is
appropriate with consideration for delayed auto-
transplantation if the kidney is salvageable.
Directly inspect the ureters for injury with a low
threshold for resection and debridement, especially
in the context of intra-abdominal gunshot injury.
Ureteral ligation with delayed percutaneous neph-
rostomy drainage and externalized ureteral stent are
acceptable temporizing measures for ureteral injury
during damage control laparotomy.
Utilize ureteroureterostomy for proximal and mid-
dle ureteral injury and ureteroneocystostomy for
distal injury.
395
Always use a retroperitoneal drain following
reconstruction without suction.
Always use absorbable sutures in the genitourinary
tract.
Operative repair is standard for intraperitoneal
bladder injury, whereas nonoperative management
with catheter drainage is standard for most extra-
peritoneal bladder injuries.
Recommended Reading
1. Alskiafi NF, Rosenstein DI (2006) Staging, evaluation, and nonop-
erative management of renal injuries. Urol Clin North Am
33:1319
2. Armenakas NA, Duckett CP, McAnich JW (1999) Indications for
nonoperative management of renal stab wounds. J Urol 161:768
3. Brewyer BN, McAninch JW, Elliott SP, Master VA (2008)
Minimally invasive endovascular techniques to treat acute renal
hemorrhage. J Urol 179:22482253
4. Broghammer JA, Fisher MB, Santucci RA (2007) Conservative
management of renal trauma: a review. Urology 70:623629
5. Buckley JC, McAninch JW (2006) Selective management of
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