Modification of an operating-room table for immediate radiographic evaluation of the urinary tract in the acute, severe trauma patient

Management of complex violent trauma to the upper urinary tract

Since abdominal and retroperitoneal trauma may endanger both the kidney and ureter, urologists are frequently called upon to evaluate an injured patient in the emergency department or in the operating room. In this setting, the suspicion of urological injury begins a clinical cascade of decision making and diagnostic testing. The recognized injury, if appropriately managed, usually heals without incident. The unrecognized injury may jeopardize the recovery of the trauma patient, such as the patient who has sustained an occult ureteral laceration and continues to have an ‘unexplained’ ileus or fever. Although urinary injury is not usually the sole compelling event in severe trauma, thoughtful consideration and treatment of renal and ureteral injuries, collectively referred to as upper urinary tract injuries, will help the surgeon to avoid troublesome management complications.

As urological surgeons, we owe a debt to early pioneers in surgical traumatology who provided the groundwork for acute care management and the management of solid and hollow organ injuries. Upon this framework, the management of urological trauma has blossomed through experience and introspection. Advances in imaging modalities, improvements and renovations of surgical technique, and critical review of outcomes data have influenced the management of genito-urinary trauma and will certainly alter the way we treat trauma patients in the next millennium. This paper illustrates some important concepts in acute genito-urinary trauma and helps towards an improved understanding of acute urological care.

Management of renal artery injuries from external trauma

We reviewed the records of 27 patients with main renal artery injury admitted to our hospitals from 1959 through June 1986. Before 1969, 7 patients were hospitalized of whom 4 had nonsurgical management with total loss of function of the affected kidney, 2 had immediate nephrectomy and 1 died before treatment. Despite the nonfunctioning kidney no hypertension developed in 3 of the 4 patients followed for an average of 72 months. After 1969 when immediate radiological assessment and surgical management of main renal artery injuries were instituted 20 patients were hospitalized. Of 4 patients treated nonoperatively loss of function of the affected kidney resulted and hypertension occurred in 1, necessitating delayed nephrectomy, after an average followup of 3.5 months. Immediate nephrectomy was performed in 10 patients and vascular repair in 3. In both survivors who underwent vascular repair followup at 24 and 36 months, respectively, showed no hypertension but loss of approximately half of the function of the affected kidney. The other 3 patients died before treatment. Aggressive management reduced markedly the time from injury to diagnosis from a median of 48 hours before 1969 to 5 hours after 1969 but only a small number of patients were suitable for vascular repair, and this procedure did not restore complete function to the kidney.

Long-term results of conservative and surgical management of blunt renal lacerations

In the management of renal lacerations most attention has centered on surgical or non-surgical treatment and little attention has been given to the long-term results. We have evaluated the medical records and radiographs of 70 patients with blunt renal lacerations; 30 had initial non-surgical management and 40 had initial surgical management. Patients with initial non-surgical management were followed up for an average of 40.4 months. Normal blood pressure and/or radiological evaluation of the kidney were noted in 22% of those who had non-surgical management (hypertension in 55%) and in 75% of those who had delayed renal surgery (hypertension in 29%). Patients with immediate surgical management were followed up for an average of 49.6 months and normal blood pressure and/or radiological evaluation of the kidney were present in 83% (no hypertension). On long-term follow-up, patients with non-surgical management had a much higher rate of hypertension and/or abnormal radiological evaluation of the kidney than those with immediate surgical management.

Management of perirenal hematoma found during laparotomy in patient with multiple injuries

The medical records of 158 patients with perirenal hematoma found during laparotomy for intra-abdominal injury from external trauma were analyzed. Small perirenal hematomas were usually associated with renal contusions and renal artery thrombosis, while large perirenal hematomas often were present with large renal lacerations, renal ruptures, and renal pedicle injuries with rupture of the renal vein, renal artery, polar artery, or branch of the renal artery. The management of the perirenal hematoma found during laparotomy depends on the degree of the underlying renal injury and not on the size or extent of the perirenal hematoma.

Type of blunt renal injury rather than associated extravasation should determine treatment

The significance of extravasation of dye during excretion urography in blunt renal injuries has been controversial, with some believing that extravasation, even if copious, is largely innocuous and characterized by spontaneous resolution, and others believing extravasation is an indication for surgical correction of the underlying blunt renal injury. Thirty-two patients with extravasation diagnosed on excretion urography after blunt external trauma were evaluated. Immediate surgical management of the renal injury was performed in 18 patients who had a contusion in 1, laceration in 13, rupture in 3, and pedicle injury in 1, and averaged 2.0 associated injuries per patient. Conservative management of the renal injury was performed in 14 patients who averaged 1.1 associated injuries per patient. Ten of the 14 patients had a large renal laceration splitting the kidney or disrupting a pole with extravasation and none settled to normal. The data showed that extravasation with a small laceration resolved spontaneously while extravasation with a major disruption of the kidney did not settle to normal.

Unilateral nonvisualization on excretory urography after external trauma

Unilateral nonvisualization on excretory urography after external trauma indicates serious consequences for the kidney, since traumatic main renal artery occlusion has been the most common cause of this finding. We evaluated 53 patients with unilateral nonvisualization on excretory urography following blunt (47) and penetrating (6) trauma. All but 1 patient had multiple injuries from severe external trauma. The renal injury causing the nonvisualization was contusion in 8 patients, laceration in 12, rupture in 12 and renal pedicle in 21. Further investigations required to diagnose the type of renal injury consisted of repeat excretory urography in 2 patients, renal arteriography in 14, renal exploration in 36 and autopsy in 1. Early diagnosis was mandatory if the kidney was to be salvaged by surgical repair of the main artery occlusion or if the appropriate management was to be used for the lesser degrees of renal injury, such as rupture, laceration and contusion.

Conservative or immediate surgical management of blunt renal injuries

From 1969 to 1981, 1,176 blunt renal injuries were recorded in 1,166 patients (10 patients had bilateral injuries). Conservative management of 27 patients with severe renal injuries resulted in a delayed renal operation in 30 per cent and total renal loss in 22 per cent. A review of the published series of the conservative management of patients with severe renal injuries (laceration, rupture and pedicle injury) shows a renal surgery rate of 13 to 68 per cent, a renal loss rate of 3 to 33 per cent and a significant complication/renal surgery rate of 13 to 76 per cent. In our patients 88 per cent with severe renal injuries had associated injuries and 73 per cent of these underwent immediate laparotomy for intra-abdominal injury. Immediate renal surgery in 59 patients with severe renal injuries resulted in a nephrectomy rate of 6.5 per cent of 31 renal lacerations, 100 per cent of 14 renal ruptures and 50 per cent of 14 pedicle injuries. Of the 14 patients with pedicle injuries 6 (43 per cent) had immediate vascular repair, with salvage of the kidney. Immediate surgical management of the patients with severe renal injuries obviated the need for a second exploration in a severely injured patient, reduced morbidity and resulted in increased renal salvage.

Immediate radiological evaluation and early surgical management of genitourinary injuries from external trauma

An immediate diagnostic evaluation of genitourinary trauma is mandatory for an early operation. A method of immediate radiological evaluation is presented and the accuracy rate in the diagnosis of the type and site of injury is detailed. The advantages of early surgical management are compared to the results with expectant management.

Urethral injury due to external trauma

Fifty-six patients with urethral injuries comprised 35 involving the posterior urethra and 21 involving the anterior urethra. Immediate retrograde urethrography confirmed the clinical diagnosis made when blood was found at the external urinary meatus after external trauma. Traffic accidents caused most of the posterior urethral injuries and were associated with severe injuries to multiple systems and a significant mortality rate (34 per cent). Primary realignment of the urethral injury by a urethral catheter in all cases of urethral rupture (plus a suprapubic cystostomy in most of these cases) resulted in a stricture rate of 62 per cent on follow-up. However, only half of these strictures required surgical correction. The incidence of incontinence was 10 per cent and of impotence 38 per cent.

Traumatic renal artery occlusion: 21 cases

Sixteen cases of unilateral and 5 cases of bilateral traumatic renal artery occlusion caused by avulsion or thrombosis are presented. The injury typically follows automobile-pedestrian accidents to young male subjects. Associated extrarenal injuries are usual but non-pedicle renal injury is infrequent. Suspicion of the unilateral injury depends upon recognition of absence of visible excretion at urography. The clue to bilateral occlusion is anuria. Diagnosis is confirmed by urgent arteriography. Hematuria was absent in 24 per cent and the injury was missed at laparotomy in 29 per cent of the initial explorations. Renal function was salvaged by arterial reconstruction in 2 cases, 12 hours and 5 months after injury respectively. Hypertension developed in 50 per cent of the cases and was generally mild.

Renal trauma in the multiple injured patient

Immediate radiological evaluation of renal injuries by a large dose or infusion excretory urogram resulted in a definitive diagnosis in 87% of the cases. Further radiological evaluation or exploration was required to make a definitive diagnosis in the remaining 13%. Blunt external trauma was responsible for 94% of the renal injuries. Less morbidity and a sharp reduction in delayed renal operation followed the introduction of immediate surgical management with the more severe types of renal injury. Clamping of the renal vessels prior to opening Gerota's fascia prevents reactivation of hemorrhage and allows for a deliverate operation with conservation of undamaged renal tissue. Associated injuries were present in 73% of the patients, including intra-abdominal injuries in 42%. The over-all nephrectomy rate of 5% in this study compares favorably to the nephrectomy rate in studies reporting the expectant management of renal injuries.

Preoperative urography in hypotensive patients with severe trauma

In hypotensive patients with severe trauma including renal injuries, the preoperative urogram is generally of poor quality. In many instances these patients are taken to the operating room with no films at all. We have proposed a protocol for the resuscitation of severely injured patients, following which we performed a carefully monitored high-dosage urogram. We demonstrated in 16 patients that diagnostic films can be obtained even in severely injured patients who were initially in shock.