Editing Upper Urinary Tract Trauma

'''Includes 2020 AUA Guideline Notes on Urotrauma'''

See [https://pubmed.ncbi.nlm.nih.gov/33053308/ Original 2020 AUA Urotrauma Guidelines]

See [[Lower Urinary Tract Trauma]] Chapter Notes

== Trauma background ==

* Leading cause of death in US population aged 1-44
* Injuries are frequently classified as blunt vs. penetrating due to differences in management and outcomes 
** Blast injuries may be associated with both penetrating and blunt trauma, and are most common in the setts of violent conflict
* Urologic organs are involved in ≈10% of abdominal traumas

== Renal Trauma ==

=== Epidemiology ===

* '''<span style="color:#ff0000">Most commonly injured GU organ in trauma'''

=== Pathogenesis ===

* '''Kidneys are particularly prone to deceleration injuries (e.g. falls, motor vehicle collisions) because they are fixed in space only by the renal pelvis and the vascular pedicle'''
* '''The pediatric kidney is believed to be more susceptible to trauma''' 
** '''Mechanisms owing to a decrease in the physical renal protective mechanisms found in children (4):''' 
**# '''Immature, more pliable thoracic cage'''
**# '''Weaker abdominal musculature'''
**# '''Less perirenal fat''' 
**# '''Sits in a lower abdominal position'''

=== Diagnosis and Evaluation ===

==== History and Physical Exam ====

===== History =====

* '''<span style="color:#ff0000">Extent of deceleration''' involved in high-velocity impact trauma
**'''<span style="color:#ff0000">Most important information in blunt renal injury'''
* '''<span style="color:#ff0000">Trauma anterior vs. posterior to the axillary line'''
**'''<span style="color:#ff0000">Trauma anterior to axially line is more likely to damage important renal structures such as the renal hilum and pedicle compared to the posterior axially line, which more commonly results in parenchymal injury'''

===== Physical Exam =====

* '''<span style="color:#ff0000">Findings indicating possible renal injury (5):'''

# '''<span style="color:#ff0000">Flank hematoma'''
# '''<span style="color:#ff0000">Abdominal or flank tenderness'''
# '''<span style="color:#ff0000">Rib fractures''' 
#* Ipsilateral rib fracture can increase the incidence of significant renal trauma by 3x
# '''<span style="color:#ff0000">Hematuria'''
#* '''<span style="color:#ff0000">The degree of hematuria and the severity of the renal injury do not consistently correlate'''; presence or absence of hematuria should not be the sole determinant in the assessment of a patient with suspected renal trauma
#'''<span style="color:#ff0000">Penetrating injuries to the low thorax or flank'''

==== Imaging ====

===== Indications =====
* '''<span style="color:#ff0000">[https://pubmed.ncbi.nlm.nih.gov/33053308/ 2020 AUA Urotrauma Guidelines]'''
**'''<span style="color:#ff0000">Indications for imaging (contrast enhanced CT with immediate and delayed films) in stable trauma patients (5):''' 
**# '''<span style="color:#ff0000">Gross hematuria''' 
**# '''<span style="color:#ff0000">Microscopic hematuria and systolic blood pressure < 90mmHG'''
**# '''<span style="color:#ff0000">Mechanism concerning for renal injury (e.g., rapid deceleration, significant blow to flank)'''
**# '''<span style="color:#ff0000">Physical exam findings concerning for renal injury (e.g. rib fracture, significant flank ecchymosis)''' 
**# '''<span style="color:#ff0000">Penetrating injury of abdomen, flank, or lower chest''' 
*** '''<span style="color:#ff0000">Generally, children can be imaged using the same criteria as adults. Children, however, often do not exhibit hypotension as adults do.'''

===== Modality =====
* '''<span style="color:#ff0000">CT abdomen/pelvis with IV contrast (with immediate and delayed images) should be performed when there is suspicion of renal injury''' (AUA)
** In children, ultrasound may be used, although CT is preferred
** In rare cases where the patient is taken to the operating room without preliminary CT scan and surgeons are considering renal exploration or nephrectomy, an intraoperative one-shot IVP (2 mL/kg IV bolus of contrast with a single image obtained 10-15 minutes later) may be used to confirm that a contralateral functioning kidney is present
** '''<span style="color:#ff0000">Major limitation of CT scan in renal trauma: inability to adequately define a renal venous injury adequately.''' 
*** '''<span style="color:#ff0000">A medial hematoma strongly suggests a venous injury, however, there is no imaging modality which can accurately diagnose a venous injury'''

===== Findings =====
*'''<span style="color:#ff0000">CT findings suspicious for significant renal injury include (6):''' 
*# '''<span style="color:#ff0000">Medial laceration'''
*# '''<span style="color:#ff0000">Medial hematoma (vascular pedicle injury)'''
*# '''<span style="color:#ff0000">Medial urinary extravasation (renal pelvis or ureteropelvic junction injury)'''
*# '''<span style="color:#ff0000">Hematoma > 3.5cm'''
*# '''<span style="color:#ff0000">Lack of contrast enhancement of the parenchyma (main renal arterial injury)'''
*# '''<span style="color:#ff0000">Active intravascular contrast extravasation (arterial injury with brisk bleeding)'''
[[File:Leftrenalarteryinjury.png|center|thumb|600x600px|Axial CT scan with contrast, red arrow showing left renal artery injury with extravasation. [[commons:File:Leftrenalarteryinjury.png|Source]]]] 

* '''<span style="color:#ff0000">Differential diagnosis of fluid collections seen on serial imaging for renal trauma (3):'''

# '''<span style="color:#ff0000">Hematoma''' - density is almost always > 30 HU
# '''<span style="color:#ff0000">Urinoma''' - density ranges from 0-20 Hounsfield units (HU)
# '''<span style="color:#ff0000">Abscess''' - associated with rim enhancement; perinephric abscess rarely occurs after renal injury

==== Grading ====

==== [https://www.aast.org/resources-detail/injury-scoring-scale#kidney AAST Grading] ====
 {| class="wikitable"
|'''<span style="color:#ff0000">Grade'''
|'''<span style="color:#ff0000">Imaging criteria (CT findings)'''
|-
|'''<span style="color:#ff0000">I'''
|
* '''Subcapsular hematoma and/or parenchymal <span style="color:#ff0000">contusion</span> without laceration'''
|-
|'''<span style="color:#ff0000">II'''
|
* '''Perirenal hematoma confined to Gerota fascia'''
* '''Parenchymal <span style="color:#ff0000">laceration ≤1 cm depth without urinary extravasation'''
|-
|'''<span style="color:#ff0000">III'''
|
* '''Parenchymal <span style="color:#ff0000">laceration >1 cm depth without collecting system rupture or urinary extravasation'''
* '''<span style="color:#ff0000">Any injury in the presence of a kidney vascular injury (pseudoaneurysm or AV fistula) or active bleeding contained within Gerota fascia'''
|-
|'''<span style="color:#ff0000">IV'''
|
* '''Parenchymal <span style="color:#ff0000">laceration extending into urinary collecting system with urinary extravasation'''
* '''<span style="color:#ff0000">Active bleeding beyond Gerota fascia</span> into the retroperitoneum or peritoneum'''
* '''<span style="color:#ff0000">Renal pelvis laceration and/or complete ureteropelvic disruption'''
* '''<span style="color:#ff0000">Segmental renal vein or artery injury'''
* '''<span style="color:#ff0000">Segmental or complete kidney infarction(s) due to vessel thrombosis without active bleeding'''
|-
|'''<span style="color:#ff0000">V'''
|
* '''<span style="color:#ff0000">Main renal artery or vein laceration or avulsion of hilum'''
* '''<span style="color:#ff0000">Devascularized kidney</span> with active bleeding'''
* '''<span style="color:#ff0000">Shattered kidney</span> with loss of identifiable parenchymal renal anatomy'''
|}
<nowiki>*</nowiki>Advance one grade for bilateral injury up to grade III
[[File:Abdotrauma.png|center|thumb|600x600px|What Grade of injury is this based on the AAST classification? [[commons:File:Abdotrauma.PNG|Source]]]]

=== Management ===

* Management of traumatic renal injuries has shifted from operative exploration to non-operative management in the vast majority of cases.
** Non-operative management of the vast majority of blunt renal injuries is firmly established; non-operative management of penetrating and high-grade renal injuries remains debatable

==== <span style="color:#ff0000">Indications for intervention</span> ====
* '''<span style="color:#ff0000">[https://pubmed.ncbi.nlm.nih.gov/33053308/ 2020 AUA Urotrauma Guidelines]</span>'''
**'''<span style="color:#ff0000">Approach based on based on hemodynamic stability</span>'''
*** '''<span style="color:#ff0000">If hemodynamically stable: non-invasive management</span>'''
**** '''<span style="color:#ff0000">Non-invasive management includes (4):'''
****#'''<span style="color:#ff0000">Close hemodynamic monitoring'''
****#'''<span style="color:#ff0000">Bed rest'''
****#'''<span style="color:#ff0000">ICU admission'''
****#'''<span style="color:#ff0000">Blood transfusion (when indicated)'''
****#'''<span style="color:#ff0000">Imaging (when indicated)</span>'''
****#*'''<span style="color:#ff0000">Indications for follow-up CT imaging (after 48 hours) in renal trauma patients (2):</span><span style="color:#ff0000">[https://pubmed.ncbi.nlm.nih.gov/33053308/ ★]'''
****#*#'''<span style="color:#ff0000">Clinical signs of complications (e.g., fever, worsening flank pain, ongoing blood loss, abdominal distention)</span>'''
****#*# '''<span style="color:#ff0000">Deep lacerations (AAST Grade IV-V)</span>'''
****#*#*AAST Grade IV-V renal injuries are prone to developing troublesome complications such as urinoma or hemorrhage
****#*#*AAST Grade I-III injuries have a low risk of complications and rarely require intervention. Routine follow-up CT imaging is not advised for uncomplicated AAST Grade I-III injuries because it is not likely to change clinical management in these cases
****'''<span style="color:#ff0000">Patients initially managed noninvasively may still require treatments (surgical, endoscopic, or angiographic) at a later time, especially those with higher grade injuries.'''
*****'''<span style="color:#ff0000">Factors associated with increased risk of bleeding and need for intervention in grade 3 and 4 injuries (3):</span>'''
*****#'''<span style="color:#ff0000">Medial hematoma</span>'''
*****#'''<span style="color:#ff0000">Hematoma > 3.5-4 cm in thickness</span>'''
*****#'''<span style="color:#ff0000">Presence of a contrast extravasation from vessels on imaging</span>'''
*****Although devitalized parenchyma has been suggested as a risk factor for development of septic complications, evidence supporting intervention for this radiographic finding is inconclusive
****Delayed renal bleeding can occur up to several weeks after injury but usually occurs within 21 days.
***'''<span style="color:#ff0000">If hemodynamically unstable: immediate intervention (surgery or selective angioembolization)</span>'''
**** '''<span style="color:#ff0000">Perform immediate intervention for hemodynamically unstable patients with radiographic findings of large perirenal hematoma (> 4 cm) and/or vascular contrast extravasation in the setting of deep or complex renal laceration (AAST Grade 3-5)[https://pubmed.ncbi.nlm.nih.gov/33053308/ ★]'''
***** Perinephric hematoma size provides a rough radiographic estimate of the magnitude of renal bleeding, and increasing hematoma size has been incrementally associated with higher intervention rates.
****'''Selected patients with bleeding from segmental renal vessels may benefit from angioembolization as an effective yet minimally invasive treatment to control bleeding'''
*****Selective embolization provides an effective and minimally invasive means to stop active bleeding from parenchymal lacerations and segmental arterial injury
*****Increasingly used in renal trauma
****'''<span style="color:#ff0000">Patients who are hemodynamically unstable despite active resuscitation should be taken to the operating room rather than angiography'''
* '''[https://pubmed.ncbi.nlm.nih.gov/31827593/ 2019 World Society of Emergency Surgery (WSES) and the American Association for the Surgery of Trauma (AAST) Guidelines]'''
** '''Non-operative management should be the treatment of choice for all hemodynamically or stabilized patients'''
**'''Isolated urinary extravasation, in itself, is not an absolute contra-indication to non-operative management in absence of other indications for laparotomy.''' 
**'''Hemodynamic stable or stabilized patients having damage to the renal pelvis not amenable to endoscopic/percutaneous techniques/stent should be considered for delayed OM in absence of other indications for immediate laparotomy.'''
**'''Hemodynamically unstable or non-responders to resuscitation should undergo operative management'''

==== <span style="color:#ff0000">Surgical management</span> ====
*Nephrectomy is a frequent result when hemodynamically unstable patients undergo surgical exploration
*'''<span style="color:#ff0000">Approach: transabdominal</span>'''
**'''Allows complete inspection of intra-abdominal organs and bowel.'''
*'''<span style="color:#ff0000">Principles of renal reconstruction after trauma include (8):</span>'''
*#'''Complete renal exposure'''
*#'''Measures for temporary vascular control'''
*#*'''<span style="color:#ff0000">Isolate the renal vessels before exploration</span> to provide the immediate capability to occlude them if massive bleeding should ensue when the Gerota fascia is opened'''
*#'''Limited debridement of nonviable tissue'''
*#'''Hemostasis by individual suture ligation of bleeding vessels'''
*#'''Watertight closure of the collecting system if necessary/possible'''
*#'''Reapproximation of the parenchymal defect'''
*#'''Coverage with nearby fascioadipose flaps (Gerota fascia or omentum) if feasible'''
*#*The open parenchyma should be covered when possible by a pedicle flap of omentum. The rich vascular and lymphatic supply of the omentum promotes wound healing and decreases the risk for delayed bleeding and urinary extravasation.
*#'''Liberal use of drains'''
*'''<span style="color:#ff0000">For major renovascular injuries in patients with 2 kidneys, speedy nephrectomy is advocated</span>'''
**In rare instances in which vascular repair is technically feasible, renal salvage rates are disappointingly low
*'''<span style="color:#ff0000">In damage control surgery, the area around the injured kidney is packed with laparotomy pads to control bleeding, with a planned return in approximately 24 hours to explore and evaluate the extent of injury.</span>'''
**This allows the cold, acidotic, and coagulopathic patient to be stabilized in the ICU before any attempt at potentially lengthy renal reconstruction is attempted.
*'''<span style="color:#ff0000">In an unstable patient, if damage control is not an option, total nephrectomy would be indicated immediately when the patient’s life would be threatened by attempted renal repair.</span>'''

==== Special Scenarios ====
===== Renal injury with urinary extravasation =====
*'''<span style="color:#ff0000">Persistent urinary extravasation can result in:'''
*#'''<span style="color:#ff0000">Urinoma'''
*#'''<span style="color:#ff0000">Perinephric infection'''
*#'''<span style="color:#ff0000">Renal loss (rarely)'''
*'''Stable patients where renal pelvis or proximal ureteral injury is not suspected: observation (AUA)'''
**'''Parenchymal collecting system injuries often resolve spontaneously.'''
***Urinary extravasation alone from a grade IV parenchymal laceration or forniceal rupture managed non-operatively has a spontaneous resolution of > 90%
*'''<span style="color:#ff0000">Indications for intervention (4):</span>'''
*#'''<span style="color:#ff0000">Suspected injury to renal pelvis or proximal ureteral avulsion</span>'''
*#*'''<span style="color:#ff0000">Suggested by large medial urinoma or contrast extravasation on delayed images without distal ureteral contrast</span>'''
*#*'''Management is either endoscopic or open depending on the clinical scenario'''
*#'''<span style="color:#ff0000">Urinoma increasing in size, purulence, or complexity</span> on follow-up imaging'''
*#'''<span style="color:#ff0000">Presence of complications such as fever, infection, increasing pain, ileus, or fistula.</span>'''
*# '''Severe renal injuries with <span style="color:#ff0000">continued urinary extravasation</span>''' (not described in 2020 AUA Guidelines)
*#*'''Placement of an internal ureteral stent for drainage may prevent prolonged urinary extravasation and decrease the chance of perirenal urinoma formation'''
* '''<span style="color:#ff0000">Options for intervention'''
*#'''<span style="color:#ff0000">Ureteral stent (preferred)'''
*#*An internalized ureteral stent is minimally invasive and alone may provide adequate drainage of the injured kidney
*#*'''A period of concomitant Foley catheter drainage may minimize pressure within the collecting system and enhance urinoma drainage'''
*# '''Percutaneous urinoma drain, percutaneous nephrostomy, or both may also be necessary'''

===== <span style="color:#ff0000">Hypertension and Renal Trauma</span> =====
*'''Hypertension is rarely noted in the early postinjury period but can occur later.'''
*'''<span style="color:#ff0000">Mechanisms for hypertension as a complication of renal trauma (4):</span>'''
*#'''<span style="color:#ff0000">Renal vascular injury, leading to stenosis or occlusion of the main renal artery or one of its branches</span>''' (one-clip, Goldblatt kidney)
*#'''<span style="color:#ff0000">Page kidney: compression of the renal parenchyma with extravasated blood or urine</span>'''
*#'''<span style="color:#ff0000">Post-trauma arteriovenous fistula</span>'''
*#'''<span style="color:#ff0000">Ureteral / UPJ obstruction</span>[https://www.ncbi.nlm.nih.gov/pubmed/29959876]'''
*#*In the first 3 scenarios, the renin-angiotensin axis is stimulated by partial renal ischemia, resulting in hypertension
* '''Can be treated with (3):'''
*#'''Anti-hypertensives'''
*#'''Observation'''
*#'''Nephrectomy (uncommonly)'''

== Ureteral Trauma ==

=== Epidemiology ===

* Rare, accounting for 1% of urologic injuries.

=== <span style="color:#ff0000">Pathogenesis ===

* '''Acute ureteral injury results from (3):''' 
*# '''Iatrogenic injury''' (open surgery, laparoscopy, and endoscopic procedures)
*# '''External violence''' from high-speed blunt mechanisms
*#*The presence of massive force injuries in the patient with blunt trauma should always increase the level of suspicion for ureteral injury
*# '''Penetrating stab and gunshot wounds'''

* '''<span style="color:#ff0000">Iatrogenic injury''' 
** '''<span style="color:#ff0000">Procedures most commonly associated with iatrogenic ureteral injuries:''' 
*** '''<span style="color:#ff0000">Hysterectomy (54%)'''
*** Colorectal surgery (14%)
*** Ovarian tumor removal (8%)
*** Transabdominal urethropexy (8%)
*** Abdominal vascular surgery
** '''Compared to open surgery, ureteral injuries during laparoscopic surgery are less likely to be recognized immediately.''' 
*** '''During laparoscopy/robotic surgery, a high index of suspicion for ureteral injury is required.'''
*** In open surgery, 1/3 of ureteral injuries are recognized immediately.
*** '''<span style="color:#ff0000">Intraoperative assessment of ureters'''  
**** Some have advocated maneuvers to check the patency of the ureter after all surgeries in which ureteric injury is commonly reported (e.g., hysterectomy).
**** '''<span style="color:#ff0000">Options (3):'''  
****# '''<span style="color:#ff0000">Direct inspection''' 
****#* '''<span style="color:#ff0000">Purposefully opening the retroperitoneum''' before or after hysterectomy has been advocated to avoid ureteral injury or at least allow intraoperative detection.
****# '''<span style="color:#ff0000">Retrograde pyelography'''
****#'''<span style="color:#ff0000">Injection of 5-10 mL of IV methylene blue or indigo carmine dye followed by cystoscopy'''  
****#* '''<span style="color:#ff0000">Poor predictor of injury'''
****#* '''<span style="color:#ff0000">Goal of cystoscopy is to document the absence of hematuria and the presence of bilateral ureteral jets'''
****#* '''IV methylene blue and indigo carmine''' are generally considered to be benign drugs, but their use has resulted in patient deaths and fetal deaths when used in pregnant women.  
****#** '''Intravenous methylene blue'''
****#***Standard 1% concentration used in clinical settings
****#****1% = 1 g in 100 ml ( =1000mg in 100ml = 10mg in 1 ml)
****#***'''Safe if used within therapeutic doses of <2mg/kg[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7693951]'''
****#**Adverse events
****#***Intravenous
****#****Burning sensation
****#****Rash
****#****Abscess
****#****Necrosis
****#****Ulceration
****#***Subcutaneous and intradermal
****#****Adverse skin reactions
****#****Superficial ulcers
****#****Abscess
****#**'''Contraindications for IV methylene blue (3):[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7693951]''' 
****#**#'''Pregnancy (potentially teratogenic)'''
****#**#'''Use of selective''' (e.g., paroxetine, sertraline, fluoxetine, fluvoxamine, citalopram) or nonselective (e.g., imipramine) '''serotonin (SSRI) and serotonin-norepinephrine (SNRI) reuptake inhibitors'''
****#**#* Methylene blue is a potent monoamine oxidase inhibitor and has caused deaths from serotonin toxicity in patients taking medications that increase serotonin levels
****#**# '''Glucose-6-phosphate dehydrogenase deficiency'''  
****#**#* Causes methemoglobinemia and hemolysis
****#**#'''Heinz body anemia'''
****#**#Renal insufficiency
****#**#*
****#** '''Contraindications for IV indigo carmine:'''  
****#**# '''Pregnancy'''
****#*** IV indigo carmine has been implicated in rare but serious cases of bronchospasm, bradycardia, hypertension, hypotension (most common), and anaphylactoid reactions.
***** '''Not effective methods'''  
****** '''Intraoperative single-shot IVP'''
****** '''Intraoperative hydration or diuretic administration'''  
******* Has been suggested to enhance ureteral visualization and potentially decrease the risk for injury
******* No data to support this method
****** '''Digital palpation of the ureter''' 
******* '''Appears to be ineffective'''
****** '''Grasping the ureter with forceps to evoke ureteral peristalsis'''  
******* '''Highly ineffective;''' should never be relied upon.
*'''<span style="color:#ff0000">Endoscopic injury'''
**Ureteroscopy should be performed alongside or over a wire placed up into the renal pelvis
**'''Factors associated with higher complication rates during ureteroscopy (4):'''
**# '''Longer surgery times'''
**# '''Treatment of renal calculi'''
**# '''Surgeon inexperience'''
**# '''Previous irradiation'''
** '''<span style="color:#ff0000">Persistence of stone basket attempts after recognition of a ureteral tear is a cause of ureteral injury during ureteroscopy.''' 
*** '''<span style="color:#ff0000">When ureteral perforation is identified, stop the procedure and place a ureteral stent'''

* '''<span style="color:#ff0000">Intraoperative ureteral manipulation''' 
** '''<span style="color:#ff0000">Common after aortoiliac and aortofemoral bypass surgery (12-20%) and may result in hydronephrosis''' 
*** '''<span style="color:#ff0000">Management: course is benign in most; if symptomatic, can be treated with steroids'''
* '''<span style="color:#ff0000">Ureteral contusion''' 
** '''Can occur in the context of a gunshot wound with blast injury'''
** '''Complications may include delayed ureteral stricture and/or overt ureteral necrosis with urinary extravasation'''
*'''<span style="color:#ff0000">Preoperative ureteral stenting'''
** '''<span style="color:#ff0000">May increase intraoperative recognition of ureteral injury'''
** '''<span style="color:#ff0000">A [https://pubmed.ncbi.nlm.nih.gov/19165412/ randomized trial] demonstrated that prophylactic stenting does not reduce the risk of ureteral injury in women undergoing gynecologic surgery'''
** Ureteral stents are not without complications

=== Diagnosis and evaluation ===

==== <span style="color:#ff0000">History and physical exam ====

* Hematuria is a non-specific indicator of urologic injury 
* '''Significant ureteral injury can occur in the absence of hematuria'''
* '''<span style="color:#ff0000">Post-operative signs and symptoms of missed ureteral injury (6):''' 
*#'''<span style="color:#ff0000">Flank pain'''
*# '''<span style="color:#ff0000">Fever'''
*# '''<span style="color:#ff0000">Leukocytosis'''
*# '''<span style="color:#ff0000">Ileus'''
*# '''<span style="color:#ff0000">Abdominal distention'''
*# '''<span style="color:#ff0000">Urinary fistula'''

==== <span style="color:#ff0000">Imaging ====

* '''<span style="color:#ff0000">Indications (contrast enhanced CT with 10 minute delayed films) for imaging (1)''' (AUA)
*# '''Stable trauma patients with suspected ureteral injuries and not proceeding directly to laparotomy'''
**If the initial delayed images do not adequately opacify the ureters, further delayed imaging may be necessary if ureteral injury is still suspected.

* '''<span style="color:#ff0000">Findings suggestive of ureteral injury (4):''' 
*#'''<span style="color:#ff0000">Contrast extravasation'''
*# '''<span style="color:#ff0000">Lack of contrast in the ureter distal to the suspected injury'''
*# '''<span style="color:#ff0000">Ipsilateral delayed pyelogram'''
*# '''<span style="color:#ff0000">Ipsilateral hydronephrosis'''

==== <span style="color:#ff0000">Other</span> ====

* '''<span style="color:#ff0000">Direct inspection during laparotomy in trauma patients with suspected ureteral injury who have not had preoperative imaging</span>'''

=== [https://www.aast.org/resources-detail/injury-scoring-scale#ureter AAST Grading] ===

* '''Grade I: contusion or hematoma without devascularization'''
* '''Grade II: laceration with < 50% transection'''
* '''Grade III: laceration with ≥ 50% transection'''
* '''Grade IV: laceration with complete transection and < 2cm devascularization'''
* '''Grade V: laceration with avulsion and > 2cm of devascularization'''
<nowiki>*</nowiki>Advance one grade for bilateral injury up to grade III

=== <span style="color:#ff0000">Management ===

* '''<span style="color:#ff0000">Based on hemodynamic stability'''
** '''<span style="color:#ff0000">If hemodynamically stable:'''
*** '''<span style="color:#ff0000">Traumatic ureteral lacerations should be repaired immediately'''
**** '''<span style="color:#ff0000">A longitudinal laceration is converted into a transverse one''' '''so as not to narrow the ureteral lumen (Heineke-Mikulicz procedure)'''
** '''<span style="color:#ff0000">If hemodynamically unstable: temporary urinary drainage followed by delayed definitive repair'''
*** '''<span style="color:#ff0000">Options for temporary urinary drainage (4):'''
***# '''<span style="color:#ff0000">Ureteral stent''' (internalized double J or exteriorized single J) '''only'''
***# '''<span style="color:#ff0000">Short period of observation with a plan for reoperation when the patient is more stable, usually within 24 hours'''
***# '''<span style="color:#ff0000">Exteriorize the ureter'''
***# '''<span style="color:#ff0000">Tie off the ureter''' (with long silk sutures for easy identification at time of delayed repair) '''<span style="color:#ff0000">and plan percutaneous nephrostomy'''
**** Definitive repair of the injury should be performed when patient has improved/stabilized
* '''<span style="color:#ff0000">Special scenarios'''
** '''<span style="color:#ff0000">Ureteral contusion'''
*** '''<span style="color:#ff0000">Options, depending on ureteral viability and clinical scenario (2):'''
***# '''<span style="color:#ff0000">Ureteral stenting'''
***# '''<span style="color:#ff0000">Resection with primary repair'''
**** '''<span style="color:#ff0000">Indications for resection with primary repair (2):'''
****# '''<span style="color:#ff0000">Severe or large areas of contusion'''
****# '''<span style="color:#ff0000">Gun-shot related ureteric contusions'''
****#* '''<span style="color:#ff0000">With a gun-shot related injury, excise devitalized tissue and an adjacent segment of normal-appearing ureter to eliminate late ischemia and stricture formation from the blast effect.''' Once both ends of the ureter have been adequately trimmed to healthy areas, mobilized, and correctly oriented, they are spatulated for ≈5-6 mm. Spatulation is performed for both ureteral segments at 180° apart
**** '''<span style="color:#ff0000">In ureteral contusions that do not appear to require excision/anastomosis, a ureteral stent should be placed'''; only truly minor injuries can go untreated, but the patients should be watched for signs of delayed urine leak.
** '''<span style="color:#ff0000">Delayed diagnosis''': '''ureteral stent'''
*** '''If ureteral stent placement unsuccesful or not possible''' (proximal ureter is completelely transected or patient instability preculdes attempts at retrograde placement)''', perform percutaneous nephrostomy with delayed repair'''
**** If nephrostomy alone does not adequately control the urine leak, options then include placement of a periureteral drain or immediate open ureteral repair
*** '''Indications for immediate repair for delayed diagnosis (within 1 week of injury) (2):'''
***# '''Injury located near a surgically closed viscus, such as bowel or vagina'''
***# '''Patient is being re-explored for other reasons'''
*** '''<span style="color:#ff0000">Campbell's 11th edition: postoperatively discovered injuries should be immediately repaired when detected within 72 hours.'''
** '''<span style="color:#ff0000">Endoscopic injury: ureteral stent +/- percutaneous nephrostomy tube'''
*** Ureteral perforation during ureteroscopy can be treated by ureteral stenting, usually with no subsequent complications
*** If endoscopic or percutaneous procedures are not possible or fail to adequately divert the urine, open or laparoscopic repair may be performed.
** '''<span style="color:#ff0000">Ureterovaginal fistula: ureteral stent'''
*** In females who undergo vaginal surgery (such as hysterectomy) or sustain penetrating pelvic trauma involving the vagina, an initially unrecognized ureteral injury can present in a delayed manner with ureterovaginal fistula.
*** Success rates range from64%-100% for ureterovaginal fistula who are initially managed with ureteral stent placement
*** Patients who failed with ureteral stent insertion went on to undergo ureteral reimplantation with or without Boari flap or psoas hitch, or transureteroureterostomy with success rates approaching 100%
** '''<span style="color:#ff0000">Ligation of the ureter: removal ligature and observe the ureter for viability'''
*** '''<span style="color:#ff0000">If viability uncertain, perform ureteroureterostomy or ureteral reimplantation'''
** '''Ureteroarterial fistula'''
*** '''A rare and potentially catastrophic condition that should be diagnosed and treated immediately because it can cause life-threatening hematuria'''
*'''<span style="color:#ff0000">Principles of managing the injured ureter:'''
*# '''Mobilize''' '''the injured ureter''', sparing the adventitia widely, so as not to devascularize the ureter further
*# '''Debride the ureter''' '''minimally''' but judiciously until edges bleed, especially in gunshot wounds
*# '''Repair ureters with spatulated, tension-free, stented, watertight anastomosis, using fine absorbable monofilament''' such as 5-0 polydioxanone (PDS) and retroperitoneal '''drainage''' afterward. Use optical magnification if necessary.
*# '''Retroperitonealize the ureteral repair''' by closing peritoneum over it if possible
*# Do not tunnel ureteroneocystostomies but rather create a widely spatulated nontunneled anastomosis
*# '''With severely injured ureters, blast effect, concomitant vascular surgery, and other complex cases, consider omental interposition to isolate the repair when possible'''
* '''<span style="color:#ff0000">Surgical management'''
** '''<span style="color:#ff0000">See [[Ureteric Stricture Disease|Ureteric Stricture Disease Chapter Notes]]'''
** '''<span style="color:#ff0000">Options for repair/reconstruction,</span> choice depends on location and length of injury'''
*** '''<span style="color:#ff0000">Upper ureteral injuries (above iliac vessesls)'''
***# '''<span style="color:#ff0000">Ureterocalycostomy'''
***# '''<span style="color:#ff0000">Ureter-ureterostomy'''
***# '''<span style="color:#ff0000">Trans-ureterostomy'''
***# '''<span style="color:#ff0000">Ileal or other interposition (not recommended in acute setting)'''
***# '''<span style="color:#ff0000">Autotransplant (not recommended in acute setting)'''
***# '''Rarely, acute nephrectomy is required to treat ureteral injury after external violence'''
*** '''<span style="color:#ff0000">Lower ureteral injuries (below iliac vessesls)'''
***# '''<span style="color:#ff0000">Ureteroneocystostomy'''
***# '''<span style="color:#ff0000">Psoas hitch'''
***# '''<span style="color:#ff0000">Boari flap'''
** '''<span style="color:#ff0000">Follow-up after repair'''
*** '''<span style="color:#ff0000">6 weeks: remove stent'''
**** At the time of stent removal, retrograde ureterogram can be perform to document healing without leakage or stenosis.
*** 10 weeks: furosemide (Lasix) renogram can document that the system continues to be unobstructed.
*** 4 months: renal US can document lack of hydronephrosis, which itself might indicate late obstruction

== Questions ==

# Describe the 2018 AAST Kidney Injury Scale 
# What are physical exam findings suggestive of renal trauma? 
# As per the 2020 AUA Guidelines on Urotrauma, what are the indications for imaging in suspected renal trauma? 
# What is the imaging of choice is suspected renal trauma?
# What is the management of renal trauma? With/without urinary extravasation? 
# When is follow-up imaging indicated in renal trauma?
# What findings on CTU are suggestive of ureteral injury? 
# What is the management of an unstable patient found to have ureteral injury intra-operatively?
# What is the management of ureteral contusion following gun shot wound?
# What are the surgical options to treat a penetrating ureteral injury following a stab wound?
# What are CT findings suggestive of significant renal injury?
# What factors are associated with increased need for intervention in grade 3 and 4 injuries?
# What are the indications for intervention in renal trauma?
# Which procedure is associated with the highest risk of ureteric injury?
# What are contraindications to IV methylene blue?
# List signs and symptoms associated with missed ureteral injury
# What is the timing of repair of a ureteric injury?
# What are the management options in an unstable patient with ureteric injury? 

== Answers ==

# Describe the 2018 AAST Kidney Injury Scale
#* Grade I: subcapsular hematoma and/or parenchymal contusion without laceration
#* Grade II: renal parenchymal laceration ≤1 cm depth without urinary extravasation OR perirenal hematoma within Gerota fascia
#* Grade III: renal parenchymal laceration >1 cm depth without collecting system rupture or urinary extravasation OR any injury in the presence of a kidney vascular injury or active bleeding contained within Gerota fascia
#* Grade IV: parenchymal laceration extending into urinary collecting system with urinary extravasation OR renal pelvis laceration and/or complete ureteropelvic disruption OR active bleeding beyond Gerota fascia into the retroperitoneum or peritoneum OR segmental renal vein or artery injury OR segmental or complete kidney infarction(s) due to vessel thrombosis without active bleeding
#* Grade V: main renal artery or vein laceration or avulsion of hilum OR devascularized kidney with active bleeding OR shattered kidney with loss of identifiable parenchymal renal anatomy
# What are physical exam findings suggestive of renal trauma?
## Flank bruising
## Broken ribs
## Hematuria
# As per the 2020 AUA Guidelines on Urotrauma, what are the indications for imaging in suspected renal trauma?
## Gross hematuria
## Microscopic hematuria and systolic blood pressure < 90mmHG
## Mechanism of injury concerning for renal injury
## Physical exam findings concerning for renal injury
## Penetrating injury
# What is the imaging of choice is suspected renal trauma?
#* CT with IV contrast with immediate and delayed images
# What is the management of renal trauma? With/without urinary extravasation?
#* In hemodynamically stable patients with renal injury, non-invasive management is preferred
#* In hemodynamically unstable patients, immediate intervention (surgery or angioembolization) is required
#* In patients with urinary extravasation due to suspected
#** Parenchymal collecting system injuries, a period of observation without intervention is advocated in stable patients where renal pelvis or proximal ureteral injury is not suspected
#** Renal pelvis or proximal ureteral avulsion (e.g., a large medial urinoma or contrast extravasation on delayed images without distal ureteral contrast), prompt intervention is required
# When is follow-up imaging indicated in renal trauma?
#* AAST Grade IV-V injury, should be done after 48 hours
#* Clinical signs complications (e.g., fever, worsening flank pain, ongoing blood loss, abdominal distention).
# What findings on CTU are suggestive of ureteral injury?
## Contrast extravasation
## Ipsilateral delayed pyelogram
## Ipsilateral hydronephrosis
## Lack of contrast in the ureter distal to the suspected injury
# What is the management of an unstable patient found to have ureteral injury intra-operatively?
#* Ureteral ligation followed by percutaneous nephrostomy tube insertion OR externalized ureteral catheter secured to the proximal end of the ureteral defect with delayed repair of the injury when patient stable
# What is the management of ureteral contusion following gun shot wound?
#* Ureteral stenting OR resection and primary repair depending on ureteral viability and clinical scenario
# What are the surgical options to treat a penetrating ureteral injury following a stab wound?
#* Injury above the iliac vessels: resection of non-viable ureteral tissue followed by uretero-ureterostomy over a ureteral stent; adjunct procedures (psoas hitch, Boari flap) may be needed
#* Below iliac vessels: ureteral reimplantation or uretero-ureterostomy over a stent

== Additional References ==
Morey, Allen F., et al. "Urotrauma guideline 2020: AUA guideline." The Journal of urology 205.1 (2021): 30-35.

Wein AJ, Kavoussi LR, Partin AW, Peters CA (eds): CAMPBELL-WALSH UROLOGY, ed 11. Philadelphia, Elsevier, 2015, chap 50