While nonoperative management for many urologic injuries has become well established, the selection of operative versus nonoperative management for certain genitourinary injuries remains controversial. Recent reviews of urologic management based on careful assessment of levels of evidence reveal a notable paucity of level 1, prospective management studies.1–6 The relatively recent efforts to accurately and uniformly describe and stage the nature of injuries and the lack of long-term follow-up leave many questions as to the best way to manage many forms of genitourinary trauma.
It has long been accepted that low-grade renal injuries can be managed nonoperatively with a high success rate. Renal contusion and subcapsular hematomas are routinely managed expectantly and only rarely would surgical or other interventions be required in such cases. These injuries heal spontaneously with few exceptions as do low-grade parenchymal lacerations. Depending on the institutional bias and experience, some urologic trauma surgeons may limit operative management of renal injuries to those in which the patient is hemodynamically unstable, almost regardless of imaging findings. Alternatively, others would include those injuries in which the grade of injury is high, presumably translating into a higher incidence of postinjury complications with nonoperative management. A number of indications for renal exploration following injury have been suggested by McAninch and Carroll.46 These include hemodynamic instability, ongoing hemorrhage requiring significant transfusion, pulsatile or expanding hematoma on exploration, and avulsion of the pedicle. These strong indications for surgical or other procedural intervention remain widely accepted. Relative indications for surgical intervention have included high-grade injuries, large perirenal hematoma, presence of urinary extravasation on contrast studies, significant devitalized fragments of parenchyma, and findings in the operating room during laparotomy with an incompletely staged injury. While there is lack of consensus regarding these relative surgical indications, there is a general trend toward nonoperative management in many of these situations, as long as hemodynamic stability is maintained.28
Proponents of the nonoperative management approach suggest that many high-grade injuries will heal without surgery, complications can frequently be managed with nonsurgical techniques (percutaneous drainage, stenting, angiographic embolization), and renal salvage rates are better overall when renal exploration is avoided. This school of thought would maintain that, with few exceptions, it is only hemodynamic instability that should prompt surgical intervention for the injured kidney, not injury stage or other predetermined imaging criteria.
In contrast, proponents of a more aggressive surgical approach would suggest that higher grades of renal injury carry an unacceptably high complication rate and that such complications, when they occur, have a high likelihood of resulting in otherwise avoidable morbidity or nephrectomy (Fig. 36-15). Proponents would suggest that early exploration and repair offer the advantage of early debridement of devitalized tissue, definitive hemostasis, repair of injuries to the collecting system, and early institution of appropriate drainage. As such, postinjury infection, urinoma, and hemorrhage risk are minimized. The descriptions of “absolute” and “relative” indications for renal exploration for trauma have been suggested to attempt to provide assistance in this decision-making process.46–48
Grade V parenchymal injury. (A) This image through the upper abdomen demonstrates the upper pole of the left kidney to be elevated by a perinephric hematoma. The upper pole is well perfused and intact. (B) A lower section reveals a large, left retroperitoneal hematoma; the right kidney is perfused and appears normal. This is an early arterial and parenchymal phase, as indicated by the degree of enhancement of the aorta and right renal cortex. (C) A more caudal image demonstrates a large, devascularized fragment of the left kidney; this represents the lower third of the kidney that has been avulsed from the perfused portion of the kidney. This injury required operative repair, which involved removal of the avulsed parenchymal fragment, suturing of the large intrarenal vascular branches that were avulsed, and reconstruction of the collecting system and the level of the junction of the lower infundibulum with the renal pelvis. While some reports suggest that some grade V injuries may be manageable nonoperatively, most clinicians consider this anatomy of injury a surgical indication. Difficulties in classifying some parenchymal injuries as grade IV versus grade V may contribute to this apparent reported variability of opinion and outcome.
For certain injuries, operative management is nearly universally accepted. These include blunt avulsion or penetrating lesions of the renovascular pedicle, AAST grade V parenchymal injuries, and ureteropelvic avulsion or complete avulsion of the fornices. While occasional case reports have suggested that grade V renal injuries can be managed nonoperatively, most studies demonstrate that 90–100% of such injuries require urgent nephrectomy.49 In reviewing the literature on nonoperative management of grade V renal injuries, the accuracy of classification is questionable, and some reports of successful management of grade V injuries probably are actually describing grade IV parenchymal lacerations. In general, attempts at nonoperative management of true grade V renal injuries are not advised and may expose the patient to substantial risk, although there remains some controversy in this area.50
Patients with significant ongoing bleeding from an injured kidney where angiographic control is not likely to correct the problem, is not available, or has failed also require prompt operative attention. For penetrating renal injuries in cases where laparotomy will occur regardless, especially when preoperative radiologic staging has not been performed or is incomplete, operative management is widely recommended.
When moderate or high-grade renal injuries are selected for nonoperative management, certain general principles apply. Such patients are at risk for continued bleeding or significant delayed bleeding, and it is important that they be observed in the surgical intensive care unit. Serial abdominal examinations are essential, as are serial laboratory studies including hemoglobin level and electrolyte status. Typed and cross-matched blood should be available for the first 24–48 hours. The patient’s hemoglobin should be maintained in such a range that a sudden drop from renewed bleeding would not be catastrophic. Particular attention should be paid to the size of the perirenal hematoma on initial imaging. Large hematomas suggest bleeding from larger intrarenal vessels and, presumably, indicate cases in which the risk of continued bleeding is greater. Elderly patients or patients with cardiovascular disease should be transfused more liberally, with a low threshold for intervention, as any sudden substantial blood loss may not be tolerated. When managing high-risk renal injuries nonoperatively, it is advisable to reimage such injuries at 48–96 hours to allow early diagnosis of complications such as enlargement of the perirenal hematoma, formation of a urinoma, or evolution of ischemic parenchyma. Early knowledge of such untoward events allows for treatment before the patient demonstrates complications such as sepsis, azotemia, or severe anemia.51
It is routine to impose a period of strict bed rest with nonoperative management of a major renal injury, although specific data to support this policy are lacking. Nevertheless, it seems reasonable to have the patient remain at bed rest for the first 24–72 hours or until significant gross hematuria resolves, and then reinstitute ambulation cautiously and in a monitored environment. If nonoperative management has been successful, patients should be instructed to avoid significant physical exertion until follow-up imaging reveals adequate healing.
Selecting between renal exploration and observation when the incompletely staged renal injury is encountered intraoperatively is difficult. Some authors recommend that the unstaged kidney be routinely explored, while others suggest a more selective approach. If no radiographic information is available, an intraoperative IVP may be selectively obtained to assist in this decision. A standard technique would involve the bolus injection of iodinated contrast (2 mL/kg body weight), and then obtaining a 10-minute excretion film. If significant anatomic distortion is observed, this is considered suggestive of major parenchymal disruption and/or injury to the collecting system, for which exploration may be of benefit. If the kidney appears grossly intact, observation would be selected, often with postoperative CT scanning for more precise imaging. Others would consider the size of the perirenal hematoma as an important parameter as well. In general, current trends in the urologic literature favor nonoperative management of most blunt renal injuries in the absence of staged grade V lesions, active bleeding noted intraoperatively, or hemodynamic instability.
Injuries to branch renal arteries from blunt trauma, resulting in segmental devascularization without laceration, can be managed nonoperatively with a low complication rate.
Penetrating injuries to the kidney are accompanied by injury to nonurologic organs in a large proportion of cases, and the majority of these patients will undergo laparotomy. These patients may or may not be imaged preoperatively. The issue of whether to explore the (suspected) renal injury in such cases is addressed in Section “Operative Management of Specific Genitourinary Injuries.” When the general trauma surgeon sees no clear operative indication and penetrating renal injury is possibly present, the urologist will have to decide on operative versus nonoperative management based on the clinical status of the patient and, preferably, on the findings of a contrast-enhanced CT scan. In general, patients with penetrating injuries to the kidney that involve the lateral and peripheral parenchyma, with small perirenal hematomas, minimal if any extravasation of contrast, and in which the pedicle and renal sinus structures are not at risk, may be safely managed nonoperatively (Fig. 36-16). Conversely, penetrating renal lesions that result in large perirenal hematomas, traverse the deep, medial renal parenchyma, renal sinus, or hilar region, or cause major urinary or vascular extravasation carry higher risks for nonoperative management (Fig. 36-17). The risk of delayed bleeding from such injuries is significant, and some authors have suggested prophylactic arteriography with embolization of violated arterial branches prior to nonoperative management. In addition, the risk of a missed associated visceral injury must be considered with nonoperative management of penetrating renal trauma. In one retrospective review of the nonoperative management of penetrating renal trauma, 55% of renal stab wounds and 24% of renal gunshot wounds were managed nonoperatively with a low complication rate.52
Penetrating renal injury, successful nonoperative management. (A) Stab wound to left flank, just posterior to midaxillary line; patient is hemodynamically stable, with gross hematuria that rapidly clears. (B) Staging computed tomography scan demonstrating laceration to lateral left kidney. There is minimal perinephric hematoma, no urinary extravasation, and no devitalized parenchyma. Injury is lateral and laceration does not extend into hilar region or renal sinus structures. Posterior descending colon is in proximity to injury, but general surgeons are prepared to manage nonoperatively. Ideal candidate for nonoperative management of a penetrating renal injury.
Penetrating renal injury, complicated. (A) Staging CT scan of abdomen following single stab wound to right posterior flank, in patient presenting with gross hematuria. Deep laceration of right kidney with moderate-sized perinephric hematoma. Injury extends into renal sinus region, although no contrast extravasation is noted. After initial attempt at nonoperative management, patient develops major secondary hemorrhage manifested by profuse gross hematuria, resulting in hypotension, and requiring transfusion of 4 U packed red blood cells. (B) Arteriogram reveals two areas of arteriocalyceal fistula, successfully managed with subselective embolization. (C) Delayed arteriogram image demonstrates wedge-shaped infarct defect due to embolization. Remainder of hospital course uneventful. Embolization is ideal means of managing this problem, as the only indication for intervention is hemorrhage.
While an uncommon injury, blunt or penetrating trauma to the adrenal gland deserves brief mention. If an adrenal hematoma is not expansile, it is managed nonoperatively as with parenchymal injuries to other solid organs. If the adrenal is explored due to the path of a stab or bullet wound, suturing to achieve hemostasis is the standard approach, while extensive destruction of the gland is treated with adrenalectomy. As each adrenal gland has several sources of arterial blood supply, devascularization from trauma is rare.
Nonoperative management of ureteral trauma has limited applications. When a ureteral injury is recognized intraoperatively, surgical repair is favored (see later).32,53,54 Reviews of outcomes of ureteral injuries indicate that most types of ureteral trauma fare better with early operative repair, as compared with delayed repair or attempts at nonoperative management, with the exception of limited iatrogenic injuries from endoscopy. This is the case for stab and gunshot wounds, as well as avulsion injuries from blunt trauma (Fig. 36-18). Nonoperative management is performed in selected patients with missed ureteral injuries or other settings of delayed diagnosis or in patients in whom damage control strategies are being adopted. Traditional urologic teaching dictates that if ureteral trauma is recognized in the early days after injury, operative repair is performed. More significantly delayed recognition is managed with utilization of endoscopic or interventional radiologic techniques (stenting or percutaneous nephrostomy diversion) followed by delayed operative reconstruction as indicated. This approach has developed due to the long-standing recognition of problems such as inflammation, edema, friability, presence of a urinoma, and increased risks and complications of reconstructive efforts encountered when operative intervention is pursued greater than 3–5 days postinjury. Ureteral contusions recognized intraoperatively, due to either penetrating or blunt trauma, may be managed nonoperatively and simply observed; however, some reports suggest that the risk of late perforation and urinary extravasation may be reduced by intraoperative insertion of a ureteral stent.55
Ureter: gunshot wound to ureter with missed injury, in a patient who had no hematuria on initial presentation. Patient developed abdominal fluid collection postlaparotomy; intravenous pyelogram demonstrated missed ureteral injury 5 days postoperatively. Injury initially managed with percutaneous nephrostomy and antegrade placement of universal stent. Long, densely fibrotic stricture of midureter developed, as shown here, ultimately requiring nephrectomy. A high index of suspicion is necessary to detect penetrating ureteral injuries at the time of initial laparotomy; outcomes are significantly improved with early recognition and prompt operative repair in such cases.
When nonoperative management is selected, retrograde ureteropyelography with attempted retrograde stent placement is often performed. Alternatively, percutaneous renal drainage may be the treatment of choice. The selection between these two approaches depends on the hemodynamic and metabolic stability of the patient, as well as specific anatomic and logistical factors. These include the appropriateness of performing a procedure under general anesthesia, the ability of the patient to undergo a procedure in a prone position (generally necessary for obtaining percutaneous renal access), the skill and availability of interventional radiology, and the expected ease of percutaneous access. The latter depends largely on the anatomy of and degree of distension of the collecting system and the presence of a perirenal hematoma. The finding of coagulopathy is often considered a relative contraindication to percutaneous renal drainage, as renal bleeding is always a risk of such procedures. Achievement of percutaneous access can be followed by antegrade ureteral stenting, if there is ureteral continuity and a guidewire can be placed across the injury into the bladder. Conversion of a nephrostomy tube to a percutaneous antegrade universal stent, which can be changed or manipulated and opened to external drainage or capped to allow internal drainage, may be attempted. Following an appropriate period, a pullback antegrade nephrostogram will determine if healing is complete and the patient is ready for stent removal with clamping of the nephrostomy tube.
When this type of management is utilized, a rate of ureteral strictures of up to 50% may be expected. A stricture may undergo an attempt at endourologic management, although delayed surgical reconstruction of the ureter is often necessary.
With blunt trauma, limited ureteral injuries with minimal extravasation may be treated nonoperatively with a retrograde stent. Retrograde pyelography is often necessary to document anatomy amenable to such management. For penetrating injuries, small-gauge shotgun pellet wounds may create minute ureteral perforations that can be managed nonoperatively as well. Such injuries may be noted at laparotomy or may be seen on a contrast-enhanced CT or intravenous or retrograde pyelography. Again, such cases represent the rare exception to the general principles favoring early operative exploration and repair when technically and medically feasible.
Nonoperative management of extraperitoneal injury to the bladder has been the standard approach for over 10 years, largely as a result of the studies of Corriere and coworkers and others in which catheter drainage alone was usually successful.56,57 An 18–20 French or larger bladder catheter should be utilized to allow free drainage in the adult. The catheter is left indwelling for 10–14 days followed by a cystogram to confirm cessation of extravasation prior to removal. After this period, >85% of bladder injuries will show absence of extravasation. If extravasation persists, another 7–10 days of catheter drainage followed by repeat cystography is appropriate. Rarely, persistent extravasation will occur after a prolonged period of catheter drainage. In such cases, CT scanning and/or cystoscopy is indicated to be sure a foreign body such as a bony spicule from a pelvic fracture or some other anatomic cause is not resulting in failure of the laceration to heal properly. Indications for initial selection of operative management instead of catheter drainage alone include concomitant injury to the vagina or rectum, injury to the bladder neck in the female, avulsion of the bladder neck in any patient,58 and the need for pelvic exploration for other surgical indications. If retropubic access is required for internal fixation of a pelvic fracture, surgical repair of the bladder is desirable to prevent continued extravasation adjacent to orthopedic hardware. Open pelvic fractures may also require operative repair of the bladder. The presence of combined extraperitoneal and intraperitoneal rupture or combined extraperitoneal bladder rupture and posterior urethral injury, for which catheter realignment is planned, would be considered an appropriate setting to proceed with operative repair of the bladder as well. Finally, clot formation with troublesome occlusion of the drainage catheter may mandate operative repair.59
Intraperitoneal ruptures of the bladder are uniformly managed with operative repair. Most such injuries result in large, stellate tears in the dome of the bladder due to the sudden rise in pressure within a full bladder as from a blow to the lower abdomen or compression by a seatbelt. Rare exceptions to the routine application of operative repair for intraperitoneal bladder rupture include minimal intraperitoneal perforations. These usually occur during cystoscopic procedures, mainly when a resectoscope is being utilized for resection of a bladder tumor or during biopsies of lesions of the dome and anterior wall, or other minimal iatrogenic injuries. Several reports have appeared in recent years describing laparoscopic techniques of repair for iatrogenic injuries,60,61 particularly when occurring during a primary laparoscopic procedure. The application of techniques of laparoscopic repair to the management of intraperitoneal rupture of the bladder from blunt trauma and other forms of bladder injury is being explored at several centers.
For penetrating injury to the bladder, nonoperative management is occasionally applicable in carefully selected and fully evaluated patients with limited defects that are extraperitoneal.62 Such patients often require proctoscopy and/or sometimes arteriography. Selectively, peritoneal lavage or laparoscopy may play a role in such cases to ensure that the peritoneal surface of the pelvis is intact. In our experience, cystoscopy and upper tract imaging (IVP or retrograde pyelography) has been helpful in assuring that the magnitude of the defect in the bladder is minimal and is likely to heal with catheter drainage alone. The considerations for conversion to operative management and postinjury monitoring and imaging and catheter management are comparable to those utilized with blunt extraperitoneal injuries.
The nature (blunt or penetrating), location of the injury (anterior vs. posterior urethra), completeness (partial vs. complete circumferential laceration), presence and seriousness of associated injuries, and the stability of the patient all impact the selection of management for urethral trauma.63–65 When urethral trauma is suspected, RUG should be performed. If the RUG reveals minimal extravasation and flow of contrast past an anterior injury from blunt trauma into the proximal urethra and bladder, some authors have suggested that a single attempt at gentle passage of a bladder catheter should be performed. Other urologists believe that even minimal blind instrumentation of the injured urethra is ill-advised, preferring an endoscopically guided approach. In this author’s opinion, endoscopically guided instrumentation of the injured urethra is preferable to blind insertion of a catheter. The most conservative recommendation is to avoid any blind instrumentation of the injured urethra by the nonurologist. For incomplete anterior urethral injuries, urethral catheterization is reasonable therapy. Catheter-realignment techniques for posterior urethral trauma fall within the realm of the experienced urologist and constitute operative therapy and will be discussed later. Penetrating injuries to the anterior urethra are generally managed with operative exploration and repair.66 Penetrating injuries to the posterior urethra may present complex challenges in management, may be complicated by adjacent rectal injury or other intrapelvic or visceral injury, and are also considered later.
While penile fractures and testicular ruptures are best managed with early recognition and operative exploration and repair, certain genital injuries due to blunt trauma may be managed nonoperatively.67 This would be the case when the injury is limited to the subcutaneous tissues, the tunica albuginea and urethra of the penis are intact, and the tunica albuginea of the testes is intact as well. For penile injuries, nonoperative management is appropriate for rupture of subcutaneous vessels resulting in limited ecchymoses or a hematoma. Scrotal trauma may be managed nonoperatively when the testis is intact and there is a limited hematocele that is not particularly uncomfortable for the patient. In most situations, however, significant genital trauma is best managed by operative exploration and repair. If physical findings are suspicious for significant injury to deep tissue or such injury cannot be ruled out by imaging studies, operative exploration is prudent. This is because the outcomes of nonoperative management of such injuries as penile fracture or testicular rupture are poor, as compared with the very high success rates of early operative repair of such injuries.68 As the relative morbidity of surgical exploration of the external genitalia is minimal and the morbidity of missed injuries or delayed recognition is significant, one should err in the direction of operative management for such injuries.45,69
A scrotal ultrasound demonstrating heterogeneity of the testicular parenchyma is suggestive of testicular rupture, even if clear loss of continuity of the investing tunica albuginea cannot specifically be identified.70 Certainly, if a clear defect in the continuity of the testicular tunic is noted on ultrasound, the diagnosis of testicular rupture should be suspected and operative repair undertaken. Patients with a significant hematocele (blood and/or clot within the tunica vaginalis compartment) with an intact testis may be observed, although they may often have a quicker recovery of activity and more rapid resolution of scrotal pain and swelling if this lesion is evacuated surgically. An intratesticular hematoma without testicular rupture is generally managed nonoperatively. At times, testicular ultrasound may demonstrate an abnormality in which a preexisting testicular lesion such as a germ cell neoplasm is suspected. Such may be the case when relatively minor trauma causes a significant intratesticular bleed or testicular rupture. When preexisting testicular pathology is suspected and nonoperative management is selected for the traumatic lesion, it is critical that the testis be reevaluated until the suspicious abnormality resolves or its continuing presence mandates further imaging and intervention.
For genital injuries involving significant loss of soft tissue or skin, nonoperative management may be appropriate as an initial approach, especially when more immediately life-threatening injuries demand priority. Wounds should be cleansed and a conservative approach should be adopted when determining whether to perform debridement of genital skin or soft tissues of marginal or questionable viability. Secondary operative management and delayed reconstruction with skin grafting or other tissue transfer techniques is often necessary when wounds are initially managed in this manner.71