18.1

Genitourinary Tract Injuries

Chapter 18

Genitourinary Tract Injuries

Introduction

Genitourinary (GU) injuries constitute approximately 5% of the

total injuries encountered in combat. Their treatment adheres

to established surgical principles of hemostasis, debridement,

and drainage. Proper radiographic evaluation prior to surgery

may replace extensive retroperitoneal exploration at the time

of laparotomy in the diagnosis of serious GU injuries.

GU wounds, aside from injuries of the external genitalia,

are typically associated with serious visceral injury.

Renal Injuries

 Most renal injuries, except for those of the renal pedicle, are

not acutely life threatening. Undiagnosed or improperly

treated injuries, however, may cause significant morbidity.

 While the vast majority of blunt renal injuries will heal

uneventfully with observation and conservative therapy, a

significant number of renal injuries in combat will come from

penetrating wounds and require exploration.

The evaluation of a suspected renal injury is based on

the type of injury, physical examination, and urinalysis.

 Hematuria is usually present in patients with renal trauma,

and gross hematuria in the adult patient is concerning for a

significant injury. The absence of hematuria, however, does

not exclude renal trauma. Renal injury must be suspected in

patients who have sustained significant concurrent injuries

such as multiple rib fractures, vertebral body or transverse

process fractures, crushing injuries of the chest or thorax, or

penetrating injury to the flank, chest, or upper abdomen.
18.2

Emergency War Surgery

 Adult patients who present with gross hematuria, microscopic hematuria with shock at any time following the injury,

and significant concurrent injury require further evaluation

of their kidneys. Computed tomography (CT) provides

excellent staging of renal injuries and aids in the decision

whether or not to explore the injured kidney.

 In the combat setting, many patients require rapid exploration

before definitive radiographic staging can be completed. An

intraoperative single-shot intravenous pyelogram (IVP) is

useful in their evaluation.

ο Procedure for one-shot IVP:

♦ 2 cc/kg of high-dose contrast is injected in either the

ED or OR setting.

♦ A single standard KUB radiograph is obtained 10

minutes following the contrast injection.

ο While high-osmolality contrast (Renografin, Hypaque, or

Conray) is adequate, low-osmolality contrast (Omnipaque,

Isovue, Optiray) is less likely to generate a reaction and is

less toxic to the kidney.

 Major renal injuries usually appear as obscured renal

shadows on IVP.

ο Detailed anatomic information regarding the degree of

renal injury or presence of urinary extravasation should

not be expected on the trauma IVP. Delayed films, however,

may improve detection of urinary extravasation.

ο The study should confirm the presence and function of

the contralateral kidney and may demonstrate congenital

anomalies such as renal ectopia or fusion. Understanding

the function of the contralateral kidney is imperative to

sound intraoperative decision making during exploration

and possible salvage of the injured kidney.

 Renal trauma is categorized by the extent of damage to the

kidney.

ο Minor injuries.

♦ Consist of renal contusions or shallow cortical lacerations.

♦ Most common after blunt trauma and usually resolve

safely without renal exploration.

♦ Hydration, antibiotics, and bed rest are the cornerstones

of successful nonoperative management.
18.3

Genitourinary Tract Injuries

ο Major injuries.

♦ Consist of deep cortical lacerations (with or without

urinary extravasation), shattered kidneys, renal vascular

pedicle injuries, or total avulsion of the renal pelvis.

♦ There is an 80% incidence of associated visceral injuries

with major renal trauma. Most cases will require a

laparotomy for evaluation and repair of concurrent

intraperitoneal injuries.

♦ Operative intervention includes debridement of

nonviable renal tissue (partial nephrectomy), closure of

the collecting system, and drainage of the retroperitoneal

area.

♦ Kidney preservation should be considered if at all

possible, although total nephrectomy may be required

for the severely damaged kidney or the unstable patient.

Vascular control of the renal pedicle can be obtained prior

to opening the perirenal fascia when control of

hemorrhage from the kidney requires exploration of the

retroperitoneum.

 Operative Technique.

ο Obtain vascular control from a periaortic approach to the

renal vascular pedicle.

♦ The small intestine is retracted laterally and superiorly,

and the posterior peritoneum is incised over the aorta.

♦ The left renal vein, crossing anterior to the aorta, must

be mobilized to gain control of either renal artery.

♦ Atraumatic vascular clamps are used to occlude the

appropriate artery.

ο While vascular control in this fashion may provide the

safest approach against renal hemorrhage and reduce the

likelihood of nephrectomy, it is not a commonly performed

maneuver by either urologists or general surgeons. Direct

reflection of the colon to expose the kidney is feasible (Fig.

18-1). A kidney pedicle clamp should be readily available

for this approach.
18.4

Emergency War Surgery

ο Damaged renal parenchyma can be locally debrided (Fig.

18-2), excised in a partial nephrectomy (Fig. 18-3), or

removed in a total nephrectomy depending on the degree

of injury and the condition of the patient.

Nephrectomy may be the best solution for major renal

injuries when associated life-threatening injuries are

present.

ο Watertight closure of the collecting system with absorbable

suture prevents the development of a urine leak.

♦ Urinary diversion is typically unnecessary if formal

renal reconstruction is accomplished.

Fig. 18-1. Exposure of left renal hilum.
18.5

Genitourinary Tract Injuries

◊ For the sake of expedience or in the presence of

associated injuries of the duodenum, pancreas, or

large bowel, diversion may be required.

◊ Tube nephrostomy, ureteral stent, or ureterostomy

may be utilized.

ο The reconstructed kidney should be covered by perirenal

fat, omentum, or fibrin sealant.

ο A closed suction drain should be left in place.

Fig. 18-2. Steps in renal debridement.

Fig. 18-3. Steps in partial nephrectomy.
18.6

Emergency War Surgery

Ureteral Injuries

Ureteral injuries are rare but are frequently overlooked

when not appropriately considered. They are more likely

in cases of retroperitoneal hematoma and injuries of the

fixed portions of the colon, duodenum, and spleen.

 Isolated ureteral injuries are rare and usually occur in

conjunction with other significant injuries. They can represent

a difficult diagnostic challenge in both the preoperative and

intraoperative settings.

ο Ureteral injuries are not reliably diagnosed by the

preoperative IVP.

ο Hematuria is frequently absent.

ο Blast injury to the urethra may produce significant delayed

complications even when the IVP is normal and the ureter

appears visibly intact. Placement of an indwelling stent is

reasonable when a high-velocity or blast injury occurs in

proximity to the ureter.

ο If a ureteral injury is initially missed and presents in a

delayed fashion, urinary diversion with a nephrostomy

tube and delayed repair at 3–6 months is a safe approach.

 Operative Technique.

ο Intraoperative localization of the ureteral injury is

facilitated by IV injection of indigo carmine or direct

injection into the collecting system under pressure.

ο Basic principles of repair.

♦ Minimal debridement.

♦ Primary tension free, 1 cm spatulated anastomosis using

an interrupted single-layer absorbable suture (4–0 or

5–0) closure technique.

♦ Internal (double J ureteral stent) and external drainage.

♦ Lengthening maneuvers.

◊ Ureteral mobilization.

◊ Kidney mobilization.

◊ Psoas hitch (Fig. 18-4).

◊ Boare flap.
18.7

Genitourinary Tract Injuries

Fig. 18-4. The psoas hitch.

a b

Fig. 18-5. Ureteroureterostomy.
18.8

Emergency War Surgery

♦ Isolate repairs with omentum or posterior peritoneum.

ο The type of repair is based on the following:

♦ Anatomical segment of the traumatized ureter (upper,

middle, and lower third).

♦ Extent of segmental loss.

♦ Other associated injuries.

♦ Clinical stability of the patient.

ο Upper or Middle ureteral injuries:

♦ Short segment loss/transection: Perform a primary

ureteroureterostomy (Fig. 18-5).

♦ Long segment loss: May require a temporizing tube/

cutaneous ureterostomy with stent placement or

ureteral ligation with tube nephrostomy.

ο Lower ureteral injuries.

♦ When the injury occurs near the bladder, an ureteroneocystostomy should be performed (Fig. 18-6). This is

typically completed by fixing the bladder to the fascial

covering of the psoas muscle using permanent suture

such as 2.0 or 3.0 Prolene. A transverse cystotomy assists

in elongating the bladder to that location and facilitates

the development of a submucosal tunnel for the

reimplanted ureter.

♦ When a distal ureteral injury is associated with a rectal

injury, ureteral reimplantation is not recommended;

temporary diversion should be performed.

Fig. 18-6. Ureteroneocystostomy.

c

b a
18.9

Genitourinary Tract Injuries

Ureteral injuries in the combat setting may be best

managed with temporary tube drainage with a small

feeding tube or ureteral stent followed by delayed

reconstruction.

Bladder Injuries

Bladder wounds should be considered in patients with

lower abdominal gunshot wounds, pelvic fractures with

gross hematuria, or those patients unable to void

following abdominal or pelvic trauma.

 Bladder disruptions can occur on the intraperitoneal or

extraperitoneal surface of the bladder. The location may

change the symptoms, complications, and management of

this injury.

 After ensuring urethral integrity in appropriate cases (see

Urethral Injuries, below), evaluation of the bladder is

performed radiographically with a cystogram.

ο Cystography is performed using a 3-film technique: (1)

scout or plain film KUB concentrating on the pelvis, (2)

full-bladder radiograph after retrograde filling of the

bladder with contrast, and (3) a postdrainage radiograph.

ο Technique: Fill the bladder by gravity with a urethral

catheter using radiopaque contrast medium elevated 20–

30 cm above the level of the abdomen. At least 300 cc (5–7

cc/kg in children) are required for an adequate study. Take

a full-bladder radiograph.

ο Drain the bladder using the catheter and take a postdrainage

radiograph. Small extraperitoneal areas of extravasation

may be apparent only on the postevacuation film.

 Operative Technique.

ο Intraperitoneal Injuries.

♦ Cystography reveals contrast medium interspersed

between loops of bowel.

♦ Management consists of immediate exploration,

multilayer repair of the injury with absorbable suture,

suprapubic tube cystostomy, and drainage of the
18.10

Emergency War Surgery

perivesical extraperitoneal space.

ο Extraperitoneal injuries.

♦ Bladder laceration is most often the result of laceration

by bony fragments from a pelvic fracture.

♦ Cystography reveals a dense, flame-like extravasation

of contrast medium in the pelvis on the postevacuation

film.

♦ The bladder usually heals with 10–14 days of Foley

catheter drainage without the need for primary repair.

If the urine is clear, catheter drainage alone is preferred

for treatment of most extraperitoneal ruptures.

♦ In cases of abdominal exploration for other injuries,

primary repair and drainage are necessary if the extraperitoneal space is entered. Repair can be completed

from inside the bladder through a cystotomy to avoid

disturbing any pelvic hematoma. Patients with

concurrent rectal injuries should be managed more

aggressively and may benefit from hematoma evacuation

and primary bladder repair.

Urethral Injuries

A urethral injury should be suspected in patients with a

scrotal hematoma, blood at the meatus, or a floating/highriding prostate. Catheterization is contraindicated until

urethral integrity is confirmed by retrograde urethrography.

 Retrograde urethrography is performed to evaluate the

anatomy of the urethra.

ο Take oblique radiographs of the pelvis to avoid “end-on”

imaging that obscures the bulbar urethra.

ο Insert the end of a sterile catheter tip syringe (60 cc) into

the urethral meatus while grasping the glans to prevent

leakage. Alternately, insert an unlubricated Foley catheter

into the fossa navicularis (approximately 3 cm) and inflate

the balloon with 3 cc of water.

ο Gently instill 15–20 cc of water-soluble contrast. The

radiograph is taken during injection.
18.11

Genitourinary Tract Injuries

ο Contrast must be seen flowing into the bladder to clear

the proximal urethra of injury. Posterior urethral injuries

seen in pelvic fractures may be missed otherwise.

ο If no injury is identified, carefully place a Foley catheter.

If any difficulty in passing the catheter is encountered,

the urethra should not be instrumented and a suprapubic

tube cystostomy is performed.

 Operative Technique.

ο The urethra is divided into anterior and posterior

(prostatic) segments by the urogenital diaphragm.

♦ Anterior urethral injuries may result from blunt trauma,

such as results from falls when astride an object

(straddle) or from penetrating injuries.

◊ Blunt trauma resulting in minor nondisruptive

urethral injuries may be managed by gentle insertion

of a 16 French Foley catheter for 7–10 days.

◊ Penetrating wounds should be managed by exploration and judicious debridement.

Small, clean lacerations may be repaired primarily

by reapproximation of the urethral edges using

interrupted 4-0 chromic suture.

Do not mobilize the entire urethra for a primary

anastomosis, because the shortened urethral

length in the pendulous urethra may produce

ventral chordee and an anastomosis under tension.

Instead, marsupialize the injured urethral segment

by suturing the skin edges to the cut edges of the

urethra. Marsupialization should be performed until

healthy urethra is encountered both proximally

and distally. Closure of the marsupialized urethra

is subsequently performed at 6 months to

reestablish urethral continuity.

♦ Posterior urethral disruption commonly occurs

following pelvic fracture injuries.

◊ Rectal examination reveals the prostate to have been

avulsed at the apex.
18.12

Emergency War Surgery

◊ Improved continence and potency rates are attained

when suprapubic tube cystostomy is used as the

initial management.

◊ Suprapubic urinary diversion is maintained for 10–14

days and urethral integrity is confirmed radiographically prior to removal of the suprapubic tube.

◊ With expectant observation, virtually all these

injuries will heal with an obliterative prostatomembranous urethral stricture, which can be repaired

secondarily in 3–6 months after reabsorption of the

pelvic hematoma.

◊ Initial exploration of the pelvic hematoma is strictly

reserved for patients with concomitant bladder neck

or rectal injury.

External Genitalia Injuries

The management of wounds to the penis, scrotum, testes,

or spermatic cord should be as conservative as possible

and consists of hemorrhage control, debridement, and

early repair to prevent deformity.

 Injuries to the penis that disrupt Buck’s fascia should be

sutured to prevent further bleeding and avoid future penile

curvature with erection. When extensive penile skin is lost,

the penis may be placed in a scrotal tunnel until a plastic

repair can be performed.

 The scrotum is highly vascularized, and extensive debridement

is usually not necessary for scrotal wounds.

ο Most penetrating scrotal injuries should be explored to

evaluate the testicle for injury and reduce the risk of

hematoma formation.

ο Most partial scrotal avulsions are best treated by primary

closure with absorbable 3-0 sutures in two layers.

ο Primary closure is selected for patients without associated

life-threatening injuries who sustained injury less than 8

hours prior. A Penrose drain or small closed drain can be

placed to reduce hematoma formation. The testes can be
18.13

Genitourinary Tract Injuries

placed in protective pockets in the medial thigh for

complete scrotal avulsion.

 It is essential, when dealing with testicular wounds, to

conserve as much tissue as possible.

ο Herniated parenchymal tissues should be debrided, and

the tunica albuginea closed by mattress sutures.

ο The testicle is placed in the scrotum or in a protective

pocket in the medial thigh.

ο A testicle should never be resected unless it is hopelessly

damaged and its blood supply destroyed.
18.14

Emergency War Surgery