Genitourinary injury occurs in 2–5% of all trauma patients and in at least 10% of patients with abdominal trauma, emphasizing the need for a close collaboration between the general and urologic trauma surgeon. This unique relationship that the urologist and general trauma surgeon share in the management of urologic injuries requires that common philosophies of management be applied.
Controversies exist in the approach to urologic trauma, and recent efforts to achieve a broad consensus in the management of diverse urologic injuries have resulted in numerous publications. One such effort, sponsored by the World Health Organization and the Societe Internationale d’Urologie, involved a 25-year review of world literature focusing on levels of evidence and development of evidence-based management recommendations.1–5 Another similar effort through the European Association of Urology (EAU) had a similar focus.6 Both produced useful syntheses of a large body of literature. The current discussion will offer a broadly applicable approach to the management of urologic trauma based on current literature and local experience and perspective.
Beginning with surgical exposure for upper tract injuries, the contemporary approach to the injured kidney is through an anterior midline abdominal incision. Access to the kidneys and ureters is generally obtained by reflecting the colon on either side medially and exposing Gerota’s fascial envelope. While modern descriptions of exposing the injured kidney often involve a discussion of first obtaining vascular control of the renal vessels prior to entering the perirenal hematoma, the important element in this practice is achieving access to the pedicle such that atraumatic vascular clamping can be achieved if significant bleeding is encountered. This can be accomplished through individually dissecting and “looping” the renal vessels through an incision in the posterior peritoneum over the aorta (which can allow access to either the left- or right-sided artery and the left-sided vein) or by first reflecting the colon on the side of injury and then obtaining vascular control or access to the pedicle. Obviously, the renal vessels should be approached first and dissected directly when there is suspicion of a renovascular injury (medial or perihilar hematoma, pulsatile hematoma). When suspicion of a renovascular injury is low, many urologic trauma surgeons successfully approach the kidney by first reflecting the colon and then achieving vascular control. This is achieved by individually dissecting the vessels, by using a vascular pedicle clamp, or through digital compression.
The kidney is located high and posteriorly in the retroperitoneum. The midline incision may need to be extended to the xiphoid process and additional upper abdominal retraction inserted for proper exposure. The kidney overlies the diaphragm, transversus abdominis aponeurosis, and quadratus lumborum muscle laterally and psoas major muscle medially. Significant bleeding from these muscles and the deep muscles of the back can occur following penetrating trauma and may confuse the picture in which brisk bleeding is occurring in the renal fossa. The kidney is enclosed in a thin but strong fibrous capsule, which should be ...