Chapter 36: Genitourinary Trauma

INTRODUCTION

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 common philosophies of management to 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 (WHO) and the Societe Internationale d’Urologie, involved a 25-year review of world literature focusing on levels of evidence and the development of evidence-based management recommendations.^1,2,3,4 Another effort through the European Association of Urology (EAU) had a similar focus.⁵ 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, local experience, and local perspective.

ANATOMY

The contemporary surgical 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 medially on either side and exposing Gerota’s fascial envelope. The exposure of an injured kidney may be achieved after obtaining vascular control of the renal vessels prior to entering the perirenal hematoma or by expeditious exploration of the retroperitoneum and manual renal vasculature. Parenchymal compression is necessary in cases of hemorrhagic unstable patients. The important step of either approach is to access the pedicle and apply atraumatic vascular clamping while damage is assessed and treated. Vascular control can be accomplished through individual dissection and “looping” of 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 the injury and then obtaining vascular control or access to the pedicle. This surgical step has been successful in experienced hands but it may increase the exploration time. In cases of low suspicion of a renovascular injury and depending on the urologic trauma surgeons’ comfort level, another successful approach to the kidney and renal hilum can be achieved by first reflecting the colon and then by manual compression, the surgeon can achieve vascular control while the assistant can evaluate and apply a “en bloc” atraumatic vascular clamp if necessary.

The kidney is located high and posterior in the retroperitoneum. The midline incision may need to be extended to the xiphoid process and additional upper abdominal retraction may need to be 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 ...