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UPPER URINARY TRACT
TRAUMA
Seminar   upper urinary tract trauma
INTRODUCTION
• Traumatic injury:-
– A leading national and international health problem.
• Trauma:-
– leading cause of death
– for persons between 1 and 44 years of age.
• In the United States:-
• 1 of every 14 deaths.
• more than 150,000 per year.
• INITIAL EVALUATION AND RESUSCITATION
– Done By:-
• emergency department physician and
• trauma surgeon
• Best care to polytrauma patients comes from
– a well-organized team of specialists,
– most often led by a surgeon experienced in trauma care.
• Urologists are a valued team member
– approximately 10% of injuries involve the genitourinary
tract.
– kidney being the most commonly injured.
• First hour of care after major injury:-
– Extremely important and
– Requires rapid assessment of the injuries and
– resuscitation
• Based on priorities established by the
American College of Surgeons’ Acute Trauma
Life Support Program.
• Mnemonic “ABCDE” defines these priorities in
order of importance:
– A, airway with cervical spine protection;
– B, breathing;
– C, circulation and control of external bleeding;
– D, disability or neurologic status; and
– E, exposure (undress) and environment (temperature
control)
RENAL INJURIES
• Most common genitourinary organs injured from
external trauma.
• 10% of abdominal trauma cases,
• Divided into:-
– Blunt Renal Trauma
– Penetrating Renal Injuries
• Blunt Renal Trauma:-
– Motor vehicle accidents,
– falls from heights, and
– Assaults
• MECHANISM:-
– Direct transmission of kinetic energy and
– rapid deceleration forces
Mechanism of Renal Injuries
• SITE:-
– major renovascular injuries occur at
retroperitoneal points of fixation such as
• renal hilum or
• ureteropelvic junction,
– resulting in renal artery thrombosis, renal vein
disruption, and renal pedicle avulsion.
• Penetrating renal injuries
– gunshot and
– stab wounds.
• Gunshot wounds comprise the great majority
of penetrating trauma with stab wounds a
distant second (86% vs. 14%).
• Stab wounds
– cause both renovascular and parenchymal
injuries.
– Common entry sites
• upper abdomen,
• flank, and
• lower chest
• Trauma to the anterior axillary line is
– more prone to damage renal hilum and pedicle,
• Trauma to the posterior axillary line
– More often resulting in parenchymal injury.
• Indicators of possible renal injury:-
– flank hematoma,
– abdominal or flank tenderness,
– rib fractures, and
– penetrating injuries to the low thorax or flank
Seminar   upper urinary tract trauma
• Evaluation and Management of renal injuries:-
– evolved over past 2 decades.
• DUE TO:-
– Advances in radiographic staging,
– improvements in hemodynamic monitoring,
– validated renal injury scoring systems,
• Allow successful nonoperative management
strategies for renal preservation.
Seminar   upper urinary tract trauma
HEMATURIA
• The best indicators of significant urinary
system injury include:-
– presence of microscopic (>5 [RBCs/HPF] or
positive dipstick finding) OR
– gross hematuria and hypotension (systolic blood
pressure <90 mm Hg).
• Degree of hematuria and severity of renal
injury do not correlate consistently.
• Gross hematuria has been observed in minor
renal contusions and
• Microscopic hematuria has been associated
with severe renal injuries.
• For example:-
– hematuria was absent in 7% of 420 grade IV renal
injuries in a recent analysis (Shariat et al, 2008a)
– and 36% of renal vascular injuries from blunt trauma
demonstrated no blood in the urine (Cass, 1989).
• Approximately 50% of injuries to the
ureteropelvic junction have no microscopic or
gross hematuria.
URINE SAMPLE
• The first aliquot of urine obtained either by
catheterization or by voiding should be used
to determine the presence of hematuria.
• Later urine samples are often diluted by
diuresis from resuscitation fluids, resulting in
an underestimation or absence of hematuria.
• Any degree of visible blood in the urine is
regarded as Gross Hematuria.
• Microscopic Hematuria detected by dipstick
analysis or microanalysis.
• The dipstick method
– rapid and
– sensitivity and specificity for detection of
microhematuria of more than 97%.
CLASSIFICATION
• Developed by The American Association for
the Surgery of Trauma.
• Based on contrast-enhanced computed
tomography (CT)
• valid predictive tool for clinical outcomes in
patients with renal trauma.
American Association for the Surgery of Trauma
Organ Injury Severity Scale for the Kidney
RADIOLOGIC IMAGING
• Criteria for radiologic imaging include
– (1) all penetrating trauma patients with a
likelihood of renal injury (abdomen, flank, or low
chest) who are hemodynamically stable;
– (2) all blunt trauma with significant mechanism of
injury, specifically rapid deceleration as would
occur in a motor vehicle accident or a fall from
heights;
– (3) all blunt trauma with gross hematuria;
– (4) all blunt trauma with hypotension defined as a
systolic pressure of less than 90 mm Hg at any time
during evaluation and resuscitation;
– (5) all pediatric patients with greater than 5 red blood
cells (RBCs)/HPF.
• Patients who are hemodynamically unstable after
initial resuscitation require surgical intervention.
Algorithm demonstrating the results of the authors’
study on radiographic assessment of renal injuries.
• Patients with microscopic hematuria
without shock can be observed clinically
without imaging studies.
• All blunt trauma patients with gross hematuria
and patients with microscopic hematuria
and shock (systolic BP<90 mm Hg any time
during evaluation and resuscitation) should
undergo renal imaging, usually with CT using IV
contrast.
• Penetrating injuries with any degree of
hematuria should be imaged.
• Children are known to be at a greater risk for
renal trauma than adults after blunt
abdominal injury
• Pediatric patients sustaining blunt renal
trauma must be carefully evaluated.
• Children have a high catecholamine output
after trauma, which maintains blood pressure
until approximately 50% of blood volume has
been lost
IMAGING STUDIES
• Contrast-enhanced computed tomography
(CT)
– gold standard for genitourinary imaging in renal
trauma
– Highly sensitive and specific,
– Provides most definitive staging information:
– Parenchymal lacerations are clearly defined;
– extravasation of contrast-enhanced urine can easily be
detected;
– associated injuries to other organs can be identified;
and
– the degree of retroperitoneal bleeding can be
assessed by the size and dimensions of the
retroperitoneal hematoma.
– Lack of uptake of contrast material in the parenchyma
suggests arterial injury.
• Arteriovenous scanning
– 80 seconds after contrast administration
– provides visualization of the kidneys in the
nephrogenic phase of contrast excretion
– necessary to detect arterial extravasation.
• Injury to the renal collecting system may be
missed; contrast material has not had time to
be excreted into the parenchyma and
collecting system adequately.
• Repeated/delayed scanning
– 10 minutes after injection of contrast
– identifies parenchymal lacerations and urinary
extravasation
CT findings suggestive of major injury
– (1) medial hematoma
– suggesting vascular injury;
– (2) medial urinary extravasation
– suggesting renal pelvis or ureteropelvic junction avulsion
– (3) lack of contrast enhancement of the
parenchyma,
– suggesting arterial injury.
VENOUS INJURY
• major limitation of CT
– inability to define a renal venous injury
adequately.
• Medial hematoma accompanied by following
findings strongly suggests a venous injury.
– normal arterial perfusion,
– normal parenchyma and
– contrast material in the collecting system.
Excretory Urography & “Single-shot” IVP
• Excretory Urography:-
– most commonly used modality to evaluate
genitourinary injuries historically.
• “Single-shot” IVP:-
– limited but important role intraoperatively.
“Single-shot” IVP
• INDICATIONS:-
– unexpected retroperitoneal hematoma
surrounding kidney during abdominal exploration
• PURPOSE:-
– to assess presence of a functioning contralateral
kidney and
– to radiographically stage the injured side.
• TECHNIQUE:-
– gain important information and
– minimize the time involved.
• PROCEDURE:-
– only a single film is taken
– 10 minutes after intravenous injection (IV push) of 2 mL/kg
of contrast material.
– If findings are not normal or near normal, the kidney
should be explored to complete the staging of the injury
and reconstruct any abnormality found.
OTHER IMAGING MODALITIES
• limited role in the evaluation of genitourinary
trauma.
• Sonography:-
– Facilitate rapid diagnosis of intra abdominal injuries
(i.e., hemoperitoneum).
– If necessary, sonography can confirm the presence of
two kidneys and
– can define a retroperitoneal hematoma.
• RENAL ARTERIOGRAPHY
– both diagnostic as well as therapeutic.
– used to define arterial injuries suspected on CT or
– to localize and control arterial bleeding (Fig. 42–4).
– useful in the primary setting with persistent bleeding
in a hemodynamically stable patient.
• Pseudoaneurysms and AV fistula are treated
by angiographic embolization to stop
secondary hemorrhage.
• Superselective embolization therapy:-
– Effective minimally invasive technique
– avoid unnecessary exploration that could
otherwise result in a nephrectomy.
NONOPERATIVE MANAGEMENT
• Has become the standard of care in
– hemodynamically stable,
– well-staged patients with American Association for
the Surgery of Trauma (AAST) grade I to III renal
injuries
• grade IV and V injuries
– more often require surgical exploration,
– but even these high-grade injuries can be managed
without renal operation if carefully staged and
selected
Seminar   upper urinary tract trauma
A Guide For Decision Making
• Patients with high-grade injuries (grades III to
V) selected for nonoperative management are
closely observed with
– serial hematocrit readings
– strict bed rest is mandatory until gross hematuria
resolves.
FOLLOW UP
• The risk of complications in patients who have been
treated conservatively increases with injury grade.
Repeat imaging 2-4 days after trauma minimises the
risk of missed complications, especially in grade 3-5
blunt injuries.
• The usefulness of frequent CT scanning after injury has
never been satisfactorily proved.
• Repeat imaging can be safely omitted for patients with
grade 1-4 injuries as long as they remain clinically well.
• Nuclear scans are useful for documenting and tracking
functional recovery following renal reconstruction.
• A decline in renal function correlates directly with
injury grade; this is independent of the mechanism of
injury and the method of management.
• Follow-up examinations should continue until healing
is documented and laboratory findings have stabilised,
although checking for latent renovascular hypertension
may need to continue for years.
• In general, the literature is inadequate on the subject
of the long-term consequences of renal tissue trauma.
Seminar   upper urinary tract trauma
DELAYED RENAL BLEEDING
• Most grades II to IV injuries resolve
uneventfully
• Delayed renal bleeding can occur in up to
25%
• Angiography with selective embolization of
bleeding vessels.
OPERATIVE MANAGEMENT
• Indications for renal exploration after trauma:-
– absolute and
– Relative
• Absolute indications:-
– (1) hemodynamic instability with shock;
– (2) expanding /pulsatile renal hematoma (usually
indicating renal artery avulsion);
– (3) suspected renal pedicle avulsion (grade 5); and
– (4) ureteropelvic junction disruption.
• Relative indications:-
– urinary extravasation together with nonviable
tissue,
– renal injury together with colon/pancreatic injury,
– a delayed diagnosis of arterial injury (which most
likely will need delayed nephrectomy).
MANAGEMENT OF SPECIAL CONDITIONS
• Intraoperative presence of a nonexpanding
retroperitoneal hematoma:-
– Nonoperative therapy is recommended,
• Urinary extravasation alone from a grade IV
parenchymal laceration or forniceal rupture:-
– managed nonoperatively
– with an expectation of spontaneous resolution of
more than 90%.
• Nonviable tissue constitute more than 25% in
association with a parenchymal laceration or
urinary extravasation or both,
– potential for complications greatly increases
– and operative management is recommended
• CRITICAL PATIENTS:-
– patient’s critical condition necessitates surgical
intervention before appropriate imaging studies and
– renal injury is obvious (manifested by perirenal
hematoma or hematuria),
– single-shot intraoperative IVP should be done.
– If findings are not normal,
• renal exploration
• reconstruction of injury.
RENAL EXPLORATION
• Best done by a transabdominal approach,
• Allows complete inspection of intra-abdominal
organs and bowel.
• Injuries to the great vessels, liver, spleen,
pancreas, or bowel can be identified and
stabilized if necessary before renal
exploration.
Renal Exploration
Surgical exploration of the
acutely injured kidney is best done by
Transabdominal approach
allows complete inspection of
intra-abdominal organs and bowel
ส
Surgical Approach to
the renal vessels and kidney
SURGICAL APPROACH TO RENAL EXPLORATION
• The renal vessels are
isolated before
exploration to provide
the immediate
capability to occlude
them if massive
bleeding ensue when
Gerota’s fascia is
opened
• The transverse colon is lifted
superiorly onto the chest,
• and the small bowel is lifted
superiorly and to the right.
• This exposes the mid
retroperitoneum.
• An incision is made over the
aorta in the retroperitoneum
just superior to the inferior
mesenteric artery.
• The incision is extended superiorly to the
ligament of Treitz.
• Exposure of the anterior surface of the aorta is
accomplished and followed superiorly to the
left renal vein, which crosses the aorta
anteriorly.
• With a vessel loop controlling the vein, the
anatomic relationships of the right and left renal
arteries as they leave the aorta provide the ability
to isolate and secure these structures with vessel
loops.
• The right renal vein can be secured through this
incision;
– if this proves difficult, reflecting the second portion of
the duodenum provides excellent exposure to the
vein.
• Large hematomas:-
– may extend over the aorta and
– obscure the landmarks for the planned initial
retroperitoneal incision.
– inferior mesenteric vein used as an anatomic guide for
an appropriate incision.
– By making the retroperitoneal incision just medial to
the inferior mesenteric vein and dissecting through
the hematoma, the anterior surface of the aorta can
be identified and followed superiorly to the crossing
left renal vein.
• The kidney is exposed by incising the peritoneum lateral to the
colon,
• followed by mobilization off Gerota fascia.
• This maneuver often requires release of the splenic (left) or hepatic
(right) attachments of the colon.
• Gerota fascia is then opened and the kidney with injury is
completely dissected from the surrounding hematoma.
• Should troublesome bleeding develop, the previously isolated
vessels can be temporarily occluded with a vascular clamp or a
vessel loop tourniquet.
• Is Early Vessel Isolation Necessary?
– Renal bleeding a major cause of nephrectomy in renal
trauma.
– Obtaining early vascular control before opening Gerota
fascia can decrease renal loss.
– McAninch and Carroll, 1982:-
• the total nephrectomy rate was reduced from 56% to 18% .
– McAninch and colleagues (1991):-
• In a series of 133 renal units in which early vessel isolation and
control before opening Gerota fascia was achieved,
• the reported renal salvage rate of 88.7%.
RENAL RECONSTRUCTION
• Principles of renal reconstruction after trauma:-
– complete renal exposure,
– measures for temporary vascular control,
– debridement of nonviable tissue,
– hemostasis by individual suture ligation of bleeding
vessels,
– watertight closure of the collecting system if possible,
– coverage or reapproximation of the parenchymal
defect, and
– judicious use of drains
RENORRHAPHY
• Involves
– exposure of the kidney,
– debridement of nonviable tissue,
– hemostasis obtained with absorbable 4-0 chromic
sutures on bleeding vessels
– closure of the collecting system,
– and approximation of the margins of the laceration (3-0
absorbable suture) with the use of renal capsule and an
absorbable hemostatic agent bolster such as Gelfoam
RENORRHAPHY
PARTIAL NEPHRECTOMY
• When polar injuries cannot be reconstructed,
• a partial nephrectomy should be done and all
nonviable tissue removed,
• hemostasis obtained, and the collecting
system closed.
PARTIAL NEPHRECTOMY
• The open parenchyma should then be covered
when possible by a pedicle flap of omentum
• With its rich vascular and lymphatic supply,
omentum promotes wound healing and
decreases the risk of delayed bleeding and
urinary extravasation.
• Should it not be available, the use of absorbable
mesh, peritoneal graft, or retroperitoneal fat has
been successful
PARTIAL NEPHRECTOMY
RENOVASCULAR INJURIES
• Uncommon
• often have associated injuries
• requires operative intervention.
• For major renovascular injuries, nephrectomy
is advocated.
• Rare instances
– where repair is possible,
– renal salvage rates are low,
– 33% renal salvage rate for main renal artery
reconstruction
– Vascular repair requires occlusion of the involved
vessel with vascular clamps.
– The lacerated main renal vessels injured by
penetrating trauma can be repaired with 5-0 non
absorbable vascular suture
VASCULAR INJURIES
RENAL ARTERY THROMBOSIS
• occurs secondary to
deceleration injuries.
• The mobility of the kidney
results in stretch on the
renal artery,
• which in turn causes the
arterial intima to disrupt.
• The consequent thrombus
occludes the vessel,
rendering the kidney
ischemic (Fig. 42–10).
• Diagnosis
– CT or angiography
– immediate renal exploration in the appropriate
candidate in an attempt to salvage the kidney,
• outcomes
– for salvage remain dismally low and
– nephrectomy is almost always required.
• With delayed diagnosis (>8 hours), the kidney
typically cannot be salvaged
DAMAGE CONTROL
• Coburn (2002):-
– Noted benefit of damage control
– improve renal salvage.
• The wound and area around the injured kidney are packed
with laparotomy pads to control bleeding
• with a planned return in 24 hours to explore and evaluate
the extent of injury.
• useful in patients with extensive injuries along with
complex renal injuries to avoid total nephrectomy.
INDICATIONS FOR NEPHRECTOMY
• Davis et al, 2006:-
– The unstable patient, with low body temperature and
poor coagulation, cannot risk an attempt at renal
repair if a normal contralateral kidney is present
• Total nephrectomy would be indicated
immediately in extensive renal injuries when the
patient’s life would be threatened by attempted
renal repair.
• Nash and colleagues (1995):-
– 77% required removal because of the extent of
parenchymal, vascular, or combined injury and
– 23% required nephrectomy in otherwise
reconstructable kidneys because of hemodynamic
instability.
COMPLICATIONS
• Persistent urinary extravasation can result in
– urinoma,
– perinephric infection,
– and even renal loss.
• MANAGEMENT:-
– initially administered systemic antibiotics and
– carefully observed with appropriate antibiotics.
• In a high percentage, the extravasation resolves spontaneously
(Matthews et al, 1997).
• Should it persist, placement of an internal ureteral stent often
corrects the problem.
COMPLICATIONS
• Delayed renal bleeding
– can occur up to several weeks after injury but
– usually occurs within 21 days.
• Management
– bed rest and hydration.
• Persistent bleeding – angiography localize the
bleeding vessel - embolization
COMPLICATIONS
• Perinephric abscess
– Rare
– persistent urinary extravasation and urinoma are
the precursors.
• Management
– Percutaneous drainage
– followed by surgical drainage if necessary.
COMPLICATIONS
• Hypertension
• seldom noted in the early post injury period
– The basic mechanisms
• (1) renal vascular injury,
– leading to stenosis or occlusion of the main renal artery or one of
its branches (Goldblatt kidney);
• (2) compression of the renal parenchyma with
extravasated blood or urine (Page kidney); and
• (3) post-trauma arteriovenous fistula.
– In these instances, the reninangiotensin axis is
stimulated by partial renal ischemia, resulting in
hypertension
URETERAL INJURIES
• "The venial sin is
injury to the ureter;
the mortal sin is
failure of
recognition" -Higgins
ETIOLOGY
• Acute ureteral injury results from:-
– external trauma,
– open surgery,
– laparoscopy, and
– endoscopic procedures.
• Uncommon:-
– intraoperative suture ligation,
– sharp incision and transection,
– avulsion,
– Devascularization
• Additionally:-
– external violence from high-speed blunt mechanisms and
– penetrating stab and gunshot wounds contributes to the overall incidence.
Seminar   upper urinary tract trauma
• COMPLICATIONS associated with
unrecognized or mismanaged ureteral injury:-
– urinoma,
– abscess,
– ureteral stricture,
– urinary fistula, and
– potential loss of an ipsilateral renal unit.
EXTERNAL TRAUMA
• ureteral damage after external violence is
quite rare,
• represent less than 1% of all GU trauma.
• penetrating injury - less than 4% and
• blunt trauma - less than 1%
• Located in the retroperitoneum between the spinal vertebra and
major muscle groups, the well-protected ureter is an unlikely target
for injury.
• Great violence must be inflicted for ureteral damage to occur.
• These patients often have significant concomitant injuries and a
devastating degree of mortality that approaches one third (Medina
et al, 1998).
• Associated visceral injury is common, predominantly
– small (39% to 65%) and
– large (28% to 33%) bowel perforation.
– 10% to 28% also have associated renal injuries.
– 5% has associated bladder injuries
Seminar   upper urinary tract trauma
BULLET INJURY
• The mechanism of bullet injury to ureter:-
– direct transection
– disruption of the delicate intramural blood supply and
subsequent necrosis.
• Due to this “blast effect,” full extent of ureteral loss is
sometimes underestimated on initial exploration.
• The ureter may appear entirely normal despite the
cavitation injury.
• Ureteric debridement should be done back to a
bleeding edge after bullet injury to remove tissue that
may have invisible microvascular damage.
BLUNT TRAUMA
• Blunt trauma associated with extreme forces
causes disruption of ureter at fixed points
along its course:-
– ureterovesical and,
– ureteropelvic junction – m/c
• UPJ disruption shows a typical pattern on contrast
CT:-
– Medial contrast extravasation or
– Circumrenal contrast extravasation
CT showing right medial extravasation of contrast
material in a patient with a renal pelvis laceration
SURGICAL INJURY
• Any difficult abdomino - pelvic surgical procedure
can potentially injure the ureter.
• Incidence varies between 0.5% and 10%
• procedures contributing to iatrogenic ureteral
injuries:
– hysterectomy (54%),
– colorectal surgery (14%),
– ovarian tumor removal (8%),
– transabdominal urethropexy (8%), and
– abdominal vascular surgery (6%)
RISK FACTORS FOR URETERIC
INJURIES
1. ANATOMICAL RISK FACTORS.
2. PATHOLOGICAL RISK FACTORS.
3. TECHNICAL RISK FACTORS
1.ANATOMICAL RISK FACTORS:
A)THE URETER:
• Has close attachment to the peritoneum.
• Closely related to female genital tract.
• Has variable course.
• Not easily seen or palpated.
2.PATHOLOGICAL RISK FACTORS:
1. Congenital anomalies of ureter or Kidney.
2. Ureteric displacement by:
Uterine size ≥12 weeks.
Prolapse.
Tumour{ovarian neoplasm}.
Cervical fibroid/Ca.
broad ligament swellings(fibroids , incarcirated
ovarian tumours or hematomas)
3.Adhesions:
Previous pelvic surgery.
Endometriosis.
PID.
Extention of carcinomatous indurations in broad
ligaments , post irradiation.
4.Distorted pelvic anatomy.
3.TECHNICAL RISK FACTORS
• Massive intraoperative haemorrhage.
• Coexistent bladder injury.
• Technical difficulties.
• Inexperienced surgeon.
Vascular procedures
• Intraoperative ureteral manipulation
– results in subsequent hydronephrosis
– common after aortoiliac and aortofemoral bypass
surgery
– 12% to 20%
• Surgical devascularization can result in
symptomatic ureteral stenosis,
– delayed in presentation by months,
– occurring in 1% to 2% of these patients
• surgical injuries to the ureter after vascular
procedures are not recognized immediately
• symptoms of ureteral injury are:-
– flank pain,
– fever,
– ileus,
– abdominal distention, and
– urinary fistula
URETEROARTERIAL FISTULAS
• Rare
• life-threatening hematuria.
• mostly between the ureter and ipsilateral iliac artery,
• ETIOLOGY:-
– previous pelvic surgery,
– radiation therapy,
– indwelling ureteral stents,
– infection,
– primary vascular disease, and
– Pregnancy
• MANAGEMENT:-
– Endovascular stent grafts
RETROGRADE PYELOGRAPHY DEMONSTRATING
URETEROILIAC ARTERY fiSTULA
URETEROSCOPIC INJURY
• Kaufman et al, 1984
– first reported ureteral injury after rigid
ureteroscopy
• Johnson et al, 2004
– ureteroscopic injury is the most common cause of
iatrogenic ureteral trauma in modern series
• Schuster et al, 2001
– perforation rate of 1% to 5%
– 0.2% requires open surgery (Butler et al, 2004)
– 5% incidence of delayed stricture occurrence.
• Factor responsible:-
– persistence of stone basket attempts even after
recognition of a ureteral tear.
• Factors associated with higher complication rates
during ureteroscopy:-
– longer surgery times,
– treatment of renal calculi,
– surgeon inexperience, and
– previous irradiation
• Factors to protect against ureteral injury:-
– smaller ureteroscopes
– flexible ureteroscopes
– Placement of guide wire
American Association for the Surgery of Trauma
Organ Injury Severity Scale for the Ureter
DIAGNOSIS
• HAEMATURIA:-
– nonspecific indicator of urologic injury.
– Absence of hematuria result from
• adynamic ureter,
• partially transected ureter or a
• complete ureteral transection
• Campbell et al, 1992
– 25% to 45% cases after violence do not demonstrate
even microscopic hematuria
– high index of suspicion is required in cases of potential
ureteral injury after penetrating trauma.
• INTRAOPERATIVELY:-
– trajectory of the knife or missile - carefully
examined during laparotomy
– ureteral exploration - all cases of potential injury.
– intraoperative inspection of retroperitoneum
most important means of diagnosing ureteral
injury due to penetrating trauma
• Methylene Blue:-
– Suspected ureteral or renal pelvis injury
– 1 to 2 mL of methylene blue dye
– directly injected into the renal pelvis
– with a 27-gauge needle to confirm the diagnosis.
IMAGING STUDIES
• Excretory Urography:-
– Ureteral injuries - unlike renal injuries - difficult to
detect
– IVP is often unhelpful,
– proving nondiagnostic 33% to 100% of the time
– intraoperative one-shot pyelography still recommend
• to detect ureteral injuries and
• assess the functional status of the contralateral system.
EXCRETORY UROGRAPHY
DEMONSTRATING EXTRAVASATION
• CT scan:-
– Ureteral injuries - difficult - diagnose on CT.
– Delayed images - must
– Findings:-
• medial extravasation of contrast material or
• nonopacification of the ipsilateral ureter
Retrograde ureterograms:-
• most sensitive radiographic test for ureteral injury,
• used in some centers as a primary diagnostic technique
• delineate the extent of ureteral injury seen on CT scan
or IVP
• Advantage:-
– allows simultaneous placement of a ureteral stent .
MANAGEMENT
• Principles of URETERIC INJURY REPAIR :
1. Mobilize the injured ureter - sparing the adventitia
widely - not to devascularize the ureter.
2. Debride the ureter liberally until the edges bleed,
3. Repair ureters with spatulated, tension-free, stented
watertight anastomosis
4. Retroperitonealize the ureteral repair by
closing peritoneum over it.
5. With severely injured ureters, blast effect,
concomitant vascular surgery, and other
complex cases,
• consider omental interposition to isolate the repair.
Identification
Courses vary among normal
individuals*
* Sampson JA, John Hopkins Med Bull
1904;156:72
- Peristalsis
- Pale glistening appearance
-Longitudinal vessels on the
surface
-Unique "snap" feeling when
pressed between 2 fingers
• Ureteroureterostomy
– A/K/A end-to-end repair
– Used in injuries to the upper two thirds of ureter.
– success rate 90% (Carlton et al, 1971).
– Complications
• urine leakage - 10% to 24%
• Other:-
– abscess and
– fistula.
• Chronic complications:-
– ureteral stenosis - 5% to 12%
• STENTING:-
– Minor ureteral contusions - Stent placement.
– Caution
• minor-appearing ureteral contusions may stricture later
• break down secondary to unappreciated microvascular
damage
– When in doubt
• the injured portion of the ureter should be debrided and
• Ureteroureterostomy used to repair the injury.
STENTING
 Insert a ureteral stent
through the anastomosis
before closure.
Advantages :
1. Maintenance of a straight
ureter with a constant
caliber during early
healing,
2. The presence of a conduit
for urine during healing,
3. Prevention of urinary
extravasation,
4. Maintenance of urinary
diversion,
5. Easy removal
MANAGEMENT OPTIONS FOR URETERAL
INJURIES AT DIFFERENT LEVELS
UPPER URETERAL INJURIES
• Ureteroureterostomy:-
– Ureteral avulsion from the renal pelvis, or
– very proximal ureteral injury,
– managed by
• reimplantation of the ureter directly into the renal
pelvis.
• Both – open and laparoscopic
UPPER URETERAL INJURIES
• Bowel Interposition:-
– long segment of ureter is destroyed,
– ureteral conduit out of ileum is created to drain the
urine,
– Success rates:-
• 81% - Boxer et al, 1979;
• 100% - Bonfig et al, 2004.
– Long-term complications
• 3% anastomotic stricture and
• 6% fistula rate
UPPER URETERAL INJURIES
• MONTI PROCEDURE:-
• short segments of bowel
• formed into a long thin tube for ureteral reconstruction
• Ileal interposition is not suggested for
acute repair of ureteral injury but rather
would be used in delayed or staged
repairs.
Ileal transposition
(Syn- Uretero-ileo-neo-cystostomy/
Uretero-entero-neo-cystostomy)
• Healthy, viable segment of
distal ileum with vascular
arcade is ''collected'' after side-
to-side stapled anastomosis
• Proximal segment of ileal loop
is opened
• Ureter is spatulated
• Full thickness of ureter is
pulled through a hole made in
the anti-mesenteric border of
the ileum and sutured over a
stent
• Sero-muscular suturing is done
• Distal end of the ileal loop is opened and puled
over the stent through an incision (over bladder
dome) and mucosal suturing done
• Seromuscular suturing done
• "Ileal conduit" is sutured to psoas fascia to
reduce tension on the anastomosis
due to gravity
• Bladder drainage for 10 days
MIDURETERAL INJURIES
• Ureteroureterostomy
• Transureteroureterostomy:-
– rarely used
– performed as a secondary or delayed procedure.
– Success rate –
• Adults - 90% to 97%
• Pediatric - 70%
– Technique –
• involves bringing the injured ureter across the midline and
• anastomosing it end to side into the uninjured ureter
Transuretero ureterostomy
LOWER URETERAL INJURIES
• Ureteroneocystostomy:-
– used to repair distal ureteral injuries
– occur very close to the bladder
– Principles:-
• creation of submucosal tunnel for nonrefluxing ureter
• tunnel length three times longer than the width of ureter.
• new ureteral orifice is constructed with the use of
interrupted sutures in a watertight and nonobstructing
fashion.
• stented.
LOWER URETERAL INJURIES
• Psoas Bladder
Hitch:-
– injuries to the
lower third of
the ureter
– high success rate
- 95% to 100%
Seminar   upper urinary tract trauma
LOWER URETERAL INJURIES
• Boari Flap:-
– Injuries to the lower two thirds of the ureter
– with long ureteral defects
– too long to be bridged by bringing the bladder up
in the psoas hitch procedure
– Technique:-
• a pedicle of bladder is swung cephalad and tubularized
to bridge the gap to the injured ureter.
Seminar   upper urinary tract trauma
DAMAGE CONTROL
• Injured ureter is managed by deferring the
definitive treatment
• Useful:-
– too unstable patient
– Unable to tolerate the operative time required to
complete the repair.
DAMAGE CONTROL
• Options:-
(1) do nothing & plan a reoperation when the
patient is more stable, usually within 24 hours;
(2) place a ureteral stent and do nothing else
(3) exteriorize the ureter; or
(4) tie off the ureter and plan percutaneous
nephrostomy
SURGICAL INJURY
• Ligation:-
– treated by removal of ligature and
– observation of the ureter for viability.
– If viability is doubtful,
• ureteroureterostomy or
• ureteral reimplantation
URETEROSCOPY INJURY
• Avulsion:-
– treated in same manner as ureteral injuries after
open or laparoscopic surgery
• Perforation:-
– perforation can be treated by stenting
– usually with no subsequent complications
Seminar   upper urinary tract trauma
Seminar   upper urinary tract trauma
Seminar   upper urinary tract trauma
Guideline Statements
Approved by the AUA
Board of Directors
April 2014
Renal trauma
• 1. Clinicians should perform diagnostic
imaging with intravenous (IV) contrast
enhanced computed tomography (CT) in
stable blunt trauma patients with gross
hematuria or microscopic hematuria and
systolic blood pressure < 90mmHG.
• 2. Clinicians should perform diagnostic
imaging with IV contrast enhanced CT in
stable trauma patients with mechanism of
injury or physical exam findings concerning
for renal injury (e.g., rapid deceleration,
significant blow to flank, rib fracture,
significant flank ecchymosis, penetrating
injury of abdomen, flank, or lower chest).
• 3. Clinicians should perform IV contrast
enhanced abdominal/pelvic CT with
immediate and delayed images when there is
suspicion of renal injury.
• 4. Clinicians should use non - invasive
management strategies in hemodynamically
stable patients with renal injury.
• 5. The surgical team must perform immediate
intervention (surgery or angioembolization in
selected situations) in hemodynamically
unstable patients with no or transient
response to resuscitation.
• 6. Clinicians may initially observe patients with
renal parenchymal injury and urinary
extravasation.
• 7. Clinicians should perform follow - up CT
imaging for renal trauma patients
• having either (a) deep lacerations (AAST Grade
IV - V) or (b) clinical signs of complications
(e.g., fever, worsening flank pain, ongoing
blood loss, abdominal distention).
• 8. Clinicians should perform urinary drainage
in the presence of complications such as
enlarging urinoma, fever, increasing pain,
ileus, fistula or infection. (Recommendation;
Evidence Strength: Grade C) Drainage should
be achieved via ureteral stent and may be
augmented by percutaneous urinoma drain,
percutaneous nephrostomy or both.
Ureteral Trauma
• 9a. Clinicians should perform IV contrast
enhanced abdominal/pelvic CT with delayed
imaging (urogram) for stable trauma patients
with suspected ureteral injuries.
• 9b. Clinicians should directly inspect the
ureters during laparotomy in patients with
suspected ureteral injury who have not had
preoperative imaging.
• 10a. Surgeons should repair traumatic ureteral
lacerations at the time of laparotomy in stable
patients.
• 10b. Surgeons may manage ureteral injuries in
unstable patients with temporary urinary
drainage followed by delayed definitive
management.
• 10c. Surgeons should manage traumatic
ureteral contusions at the time of laparotomy
with ureteral stenting or resection and
primary repair depending on ureteral viability
and clinical scenario.
• 11a. Surgeons should attempt ureteral stent
placement in patients with incomplete
ureteral injuries diagnosed postoperatively or
in a delayed setting.
• 11b. Surgeons should perform percutaneous
nephrostomy with delayed repair as needed in
patients when stent placement is unsuccessful
or not possible.
• 12a. Surgeons should repair ureteral injuries
located proximal to the iliac vessels with
primary repair over a ureteral stent, when
possible.
• 12b. Surgeons should repair ureteral injuries
located distal to the iliac vessels with ureteral
reimplantation or primary repair over a
ureteral stent, when possible.
• 13a. Surgeons should manage endoscopic
ureteral injuries with a ureteral stent and/or
percutaneous nephrostomy tube, when
possible.
• 13b. Surgeons may manage endoscopic
ureteral injuries with open repair when
endoscopic or percutaneous procedures are
not possible or fail to adequately divert the
urine.
Seminar   upper urinary tract trauma

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Seminar upper urinary tract trauma

  • 3. INTRODUCTION • Traumatic injury:- – A leading national and international health problem. • Trauma:- – leading cause of death – for persons between 1 and 44 years of age. • In the United States:- • 1 of every 14 deaths. • more than 150,000 per year.
  • 4. • INITIAL EVALUATION AND RESUSCITATION – Done By:- • emergency department physician and • trauma surgeon • Best care to polytrauma patients comes from – a well-organized team of specialists, – most often led by a surgeon experienced in trauma care. • Urologists are a valued team member – approximately 10% of injuries involve the genitourinary tract. – kidney being the most commonly injured.
  • 5. • First hour of care after major injury:- – Extremely important and – Requires rapid assessment of the injuries and – resuscitation • Based on priorities established by the American College of Surgeons’ Acute Trauma Life Support Program.
  • 6. • Mnemonic “ABCDE” defines these priorities in order of importance: – A, airway with cervical spine protection; – B, breathing; – C, circulation and control of external bleeding; – D, disability or neurologic status; and – E, exposure (undress) and environment (temperature control)
  • 7. RENAL INJURIES • Most common genitourinary organs injured from external trauma. • 10% of abdominal trauma cases, • Divided into:- – Blunt Renal Trauma – Penetrating Renal Injuries
  • 8. • Blunt Renal Trauma:- – Motor vehicle accidents, – falls from heights, and – Assaults • MECHANISM:- – Direct transmission of kinetic energy and – rapid deceleration forces
  • 10. • SITE:- – major renovascular injuries occur at retroperitoneal points of fixation such as • renal hilum or • ureteropelvic junction, – resulting in renal artery thrombosis, renal vein disruption, and renal pedicle avulsion.
  • 11. • Penetrating renal injuries – gunshot and – stab wounds. • Gunshot wounds comprise the great majority of penetrating trauma with stab wounds a distant second (86% vs. 14%).
  • 12. • Stab wounds – cause both renovascular and parenchymal injuries. – Common entry sites • upper abdomen, • flank, and • lower chest
  • 13. • Trauma to the anterior axillary line is – more prone to damage renal hilum and pedicle, • Trauma to the posterior axillary line – More often resulting in parenchymal injury. • Indicators of possible renal injury:- – flank hematoma, – abdominal or flank tenderness, – rib fractures, and – penetrating injuries to the low thorax or flank
  • 15. • Evaluation and Management of renal injuries:- – evolved over past 2 decades. • DUE TO:- – Advances in radiographic staging, – improvements in hemodynamic monitoring, – validated renal injury scoring systems, • Allow successful nonoperative management strategies for renal preservation.
  • 17. HEMATURIA • The best indicators of significant urinary system injury include:- – presence of microscopic (>5 [RBCs/HPF] or positive dipstick finding) OR – gross hematuria and hypotension (systolic blood pressure <90 mm Hg).
  • 18. • Degree of hematuria and severity of renal injury do not correlate consistently. • Gross hematuria has been observed in minor renal contusions and • Microscopic hematuria has been associated with severe renal injuries.
  • 19. • For example:- – hematuria was absent in 7% of 420 grade IV renal injuries in a recent analysis (Shariat et al, 2008a) – and 36% of renal vascular injuries from blunt trauma demonstrated no blood in the urine (Cass, 1989). • Approximately 50% of injuries to the ureteropelvic junction have no microscopic or gross hematuria.
  • 20. URINE SAMPLE • The first aliquot of urine obtained either by catheterization or by voiding should be used to determine the presence of hematuria. • Later urine samples are often diluted by diuresis from resuscitation fluids, resulting in an underestimation or absence of hematuria.
  • 21. • Any degree of visible blood in the urine is regarded as Gross Hematuria. • Microscopic Hematuria detected by dipstick analysis or microanalysis. • The dipstick method – rapid and – sensitivity and specificity for detection of microhematuria of more than 97%.
  • 22. CLASSIFICATION • Developed by The American Association for the Surgery of Trauma. • Based on contrast-enhanced computed tomography (CT) • valid predictive tool for clinical outcomes in patients with renal trauma.
  • 23. American Association for the Surgery of Trauma Organ Injury Severity Scale for the Kidney
  • 24. RADIOLOGIC IMAGING • Criteria for radiologic imaging include – (1) all penetrating trauma patients with a likelihood of renal injury (abdomen, flank, or low chest) who are hemodynamically stable; – (2) all blunt trauma with significant mechanism of injury, specifically rapid deceleration as would occur in a motor vehicle accident or a fall from heights;
  • 25. – (3) all blunt trauma with gross hematuria; – (4) all blunt trauma with hypotension defined as a systolic pressure of less than 90 mm Hg at any time during evaluation and resuscitation; – (5) all pediatric patients with greater than 5 red blood cells (RBCs)/HPF. • Patients who are hemodynamically unstable after initial resuscitation require surgical intervention.
  • 26. Algorithm demonstrating the results of the authors’ study on radiographic assessment of renal injuries.
  • 27. • Patients with microscopic hematuria without shock can be observed clinically without imaging studies. • All blunt trauma patients with gross hematuria and patients with microscopic hematuria and shock (systolic BP<90 mm Hg any time during evaluation and resuscitation) should undergo renal imaging, usually with CT using IV contrast.
  • 28. • Penetrating injuries with any degree of hematuria should be imaged. • Children are known to be at a greater risk for renal trauma than adults after blunt abdominal injury
  • 29. • Pediatric patients sustaining blunt renal trauma must be carefully evaluated. • Children have a high catecholamine output after trauma, which maintains blood pressure until approximately 50% of blood volume has been lost
  • 30. IMAGING STUDIES • Contrast-enhanced computed tomography (CT) – gold standard for genitourinary imaging in renal trauma – Highly sensitive and specific, – Provides most definitive staging information: – Parenchymal lacerations are clearly defined;
  • 31. – extravasation of contrast-enhanced urine can easily be detected; – associated injuries to other organs can be identified; and – the degree of retroperitoneal bleeding can be assessed by the size and dimensions of the retroperitoneal hematoma. – Lack of uptake of contrast material in the parenchyma suggests arterial injury.
  • 32. • Arteriovenous scanning – 80 seconds after contrast administration – provides visualization of the kidneys in the nephrogenic phase of contrast excretion – necessary to detect arterial extravasation.
  • 33. • Injury to the renal collecting system may be missed; contrast material has not had time to be excreted into the parenchyma and collecting system adequately. • Repeated/delayed scanning – 10 minutes after injection of contrast – identifies parenchymal lacerations and urinary extravasation
  • 34. CT findings suggestive of major injury – (1) medial hematoma – suggesting vascular injury; – (2) medial urinary extravasation – suggesting renal pelvis or ureteropelvic junction avulsion – (3) lack of contrast enhancement of the parenchyma, – suggesting arterial injury.
  • 35. VENOUS INJURY • major limitation of CT – inability to define a renal venous injury adequately. • Medial hematoma accompanied by following findings strongly suggests a venous injury. – normal arterial perfusion, – normal parenchyma and – contrast material in the collecting system.
  • 36. Excretory Urography & “Single-shot” IVP • Excretory Urography:- – most commonly used modality to evaluate genitourinary injuries historically. • “Single-shot” IVP:- – limited but important role intraoperatively.
  • 37. “Single-shot” IVP • INDICATIONS:- – unexpected retroperitoneal hematoma surrounding kidney during abdominal exploration • PURPOSE:- – to assess presence of a functioning contralateral kidney and – to radiographically stage the injured side.
  • 38. • TECHNIQUE:- – gain important information and – minimize the time involved. • PROCEDURE:- – only a single film is taken – 10 minutes after intravenous injection (IV push) of 2 mL/kg of contrast material. – If findings are not normal or near normal, the kidney should be explored to complete the staging of the injury and reconstruct any abnormality found.
  • 39. OTHER IMAGING MODALITIES • limited role in the evaluation of genitourinary trauma. • Sonography:- – Facilitate rapid diagnosis of intra abdominal injuries (i.e., hemoperitoneum). – If necessary, sonography can confirm the presence of two kidneys and – can define a retroperitoneal hematoma.
  • 40. • RENAL ARTERIOGRAPHY – both diagnostic as well as therapeutic. – used to define arterial injuries suspected on CT or – to localize and control arterial bleeding (Fig. 42–4). – useful in the primary setting with persistent bleeding in a hemodynamically stable patient.
  • 41. • Pseudoaneurysms and AV fistula are treated by angiographic embolization to stop secondary hemorrhage. • Superselective embolization therapy:- – Effective minimally invasive technique – avoid unnecessary exploration that could otherwise result in a nephrectomy.
  • 42. NONOPERATIVE MANAGEMENT • Has become the standard of care in – hemodynamically stable, – well-staged patients with American Association for the Surgery of Trauma (AAST) grade I to III renal injuries • grade IV and V injuries – more often require surgical exploration, – but even these high-grade injuries can be managed without renal operation if carefully staged and selected
  • 44. A Guide For Decision Making
  • 45. • Patients with high-grade injuries (grades III to V) selected for nonoperative management are closely observed with – serial hematocrit readings – strict bed rest is mandatory until gross hematuria resolves.
  • 46. FOLLOW UP • The risk of complications in patients who have been treated conservatively increases with injury grade. Repeat imaging 2-4 days after trauma minimises the risk of missed complications, especially in grade 3-5 blunt injuries. • The usefulness of frequent CT scanning after injury has never been satisfactorily proved. • Repeat imaging can be safely omitted for patients with grade 1-4 injuries as long as they remain clinically well. • Nuclear scans are useful for documenting and tracking functional recovery following renal reconstruction.
  • 47. • A decline in renal function correlates directly with injury grade; this is independent of the mechanism of injury and the method of management. • Follow-up examinations should continue until healing is documented and laboratory findings have stabilised, although checking for latent renovascular hypertension may need to continue for years. • In general, the literature is inadequate on the subject of the long-term consequences of renal tissue trauma.
  • 49. DELAYED RENAL BLEEDING • Most grades II to IV injuries resolve uneventfully • Delayed renal bleeding can occur in up to 25% • Angiography with selective embolization of bleeding vessels.
  • 50. OPERATIVE MANAGEMENT • Indications for renal exploration after trauma:- – absolute and – Relative • Absolute indications:- – (1) hemodynamic instability with shock; – (2) expanding /pulsatile renal hematoma (usually indicating renal artery avulsion); – (3) suspected renal pedicle avulsion (grade 5); and – (4) ureteropelvic junction disruption.
  • 51. • Relative indications:- – urinary extravasation together with nonviable tissue, – renal injury together with colon/pancreatic injury, – a delayed diagnosis of arterial injury (which most likely will need delayed nephrectomy).
  • 52. MANAGEMENT OF SPECIAL CONDITIONS • Intraoperative presence of a nonexpanding retroperitoneal hematoma:- – Nonoperative therapy is recommended, • Urinary extravasation alone from a grade IV parenchymal laceration or forniceal rupture:- – managed nonoperatively – with an expectation of spontaneous resolution of more than 90%.
  • 53. • Nonviable tissue constitute more than 25% in association with a parenchymal laceration or urinary extravasation or both, – potential for complications greatly increases – and operative management is recommended
  • 54. • CRITICAL PATIENTS:- – patient’s critical condition necessitates surgical intervention before appropriate imaging studies and – renal injury is obvious (manifested by perirenal hematoma or hematuria), – single-shot intraoperative IVP should be done. – If findings are not normal, • renal exploration • reconstruction of injury.
  • 55. RENAL EXPLORATION • Best done by a transabdominal approach, • Allows complete inspection of intra-abdominal organs and bowel. • Injuries to the great vessels, liver, spleen, pancreas, or bowel can be identified and stabilized if necessary before renal exploration.
  • 56. Renal Exploration Surgical exploration of the acutely injured kidney is best done by Transabdominal approach allows complete inspection of intra-abdominal organs and bowel ส
  • 57. Surgical Approach to the renal vessels and kidney
  • 58. SURGICAL APPROACH TO RENAL EXPLORATION • The renal vessels are isolated before exploration to provide the immediate capability to occlude them if massive bleeding ensue when Gerota’s fascia is opened
  • 59. • The transverse colon is lifted superiorly onto the chest, • and the small bowel is lifted superiorly and to the right. • This exposes the mid retroperitoneum. • An incision is made over the aorta in the retroperitoneum just superior to the inferior mesenteric artery.
  • 60. • The incision is extended superiorly to the ligament of Treitz. • Exposure of the anterior surface of the aorta is accomplished and followed superiorly to the left renal vein, which crosses the aorta anteriorly.
  • 61. • With a vessel loop controlling the vein, the anatomic relationships of the right and left renal arteries as they leave the aorta provide the ability to isolate and secure these structures with vessel loops. • The right renal vein can be secured through this incision; – if this proves difficult, reflecting the second portion of the duodenum provides excellent exposure to the vein.
  • 62. • Large hematomas:- – may extend over the aorta and – obscure the landmarks for the planned initial retroperitoneal incision. – inferior mesenteric vein used as an anatomic guide for an appropriate incision. – By making the retroperitoneal incision just medial to the inferior mesenteric vein and dissecting through the hematoma, the anterior surface of the aorta can be identified and followed superiorly to the crossing left renal vein.
  • 63. • The kidney is exposed by incising the peritoneum lateral to the colon, • followed by mobilization off Gerota fascia. • This maneuver often requires release of the splenic (left) or hepatic (right) attachments of the colon. • Gerota fascia is then opened and the kidney with injury is completely dissected from the surrounding hematoma. • Should troublesome bleeding develop, the previously isolated vessels can be temporarily occluded with a vascular clamp or a vessel loop tourniquet.
  • 64. • Is Early Vessel Isolation Necessary? – Renal bleeding a major cause of nephrectomy in renal trauma. – Obtaining early vascular control before opening Gerota fascia can decrease renal loss. – McAninch and Carroll, 1982:- • the total nephrectomy rate was reduced from 56% to 18% . – McAninch and colleagues (1991):- • In a series of 133 renal units in which early vessel isolation and control before opening Gerota fascia was achieved, • the reported renal salvage rate of 88.7%.
  • 65. RENAL RECONSTRUCTION • Principles of renal reconstruction after trauma:- – complete renal exposure, – measures for temporary vascular control, – debridement of nonviable tissue, – hemostasis by individual suture ligation of bleeding vessels, – watertight closure of the collecting system if possible, – coverage or reapproximation of the parenchymal defect, and – judicious use of drains
  • 66. RENORRHAPHY • Involves – exposure of the kidney, – debridement of nonviable tissue, – hemostasis obtained with absorbable 4-0 chromic sutures on bleeding vessels – closure of the collecting system, – and approximation of the margins of the laceration (3-0 absorbable suture) with the use of renal capsule and an absorbable hemostatic agent bolster such as Gelfoam
  • 68. PARTIAL NEPHRECTOMY • When polar injuries cannot be reconstructed, • a partial nephrectomy should be done and all nonviable tissue removed, • hemostasis obtained, and the collecting system closed.
  • 69. PARTIAL NEPHRECTOMY • The open parenchyma should then be covered when possible by a pedicle flap of omentum • With its rich vascular and lymphatic supply, omentum promotes wound healing and decreases the risk of delayed bleeding and urinary extravasation. • Should it not be available, the use of absorbable mesh, peritoneal graft, or retroperitoneal fat has been successful
  • 71. RENOVASCULAR INJURIES • Uncommon • often have associated injuries • requires operative intervention. • For major renovascular injuries, nephrectomy is advocated.
  • 72. • Rare instances – where repair is possible, – renal salvage rates are low, – 33% renal salvage rate for main renal artery reconstruction – Vascular repair requires occlusion of the involved vessel with vascular clamps. – The lacerated main renal vessels injured by penetrating trauma can be repaired with 5-0 non absorbable vascular suture
  • 74. RENAL ARTERY THROMBOSIS • occurs secondary to deceleration injuries. • The mobility of the kidney results in stretch on the renal artery, • which in turn causes the arterial intima to disrupt. • The consequent thrombus occludes the vessel, rendering the kidney ischemic (Fig. 42–10).
  • 75. • Diagnosis – CT or angiography – immediate renal exploration in the appropriate candidate in an attempt to salvage the kidney, • outcomes – for salvage remain dismally low and – nephrectomy is almost always required. • With delayed diagnosis (>8 hours), the kidney typically cannot be salvaged
  • 76. DAMAGE CONTROL • Coburn (2002):- – Noted benefit of damage control – improve renal salvage. • The wound and area around the injured kidney are packed with laparotomy pads to control bleeding • with a planned return in 24 hours to explore and evaluate the extent of injury. • useful in patients with extensive injuries along with complex renal injuries to avoid total nephrectomy.
  • 77. INDICATIONS FOR NEPHRECTOMY • Davis et al, 2006:- – The unstable patient, with low body temperature and poor coagulation, cannot risk an attempt at renal repair if a normal contralateral kidney is present • Total nephrectomy would be indicated immediately in extensive renal injuries when the patient’s life would be threatened by attempted renal repair.
  • 78. • Nash and colleagues (1995):- – 77% required removal because of the extent of parenchymal, vascular, or combined injury and – 23% required nephrectomy in otherwise reconstructable kidneys because of hemodynamic instability.
  • 79. COMPLICATIONS • Persistent urinary extravasation can result in – urinoma, – perinephric infection, – and even renal loss. • MANAGEMENT:- – initially administered systemic antibiotics and – carefully observed with appropriate antibiotics. • In a high percentage, the extravasation resolves spontaneously (Matthews et al, 1997). • Should it persist, placement of an internal ureteral stent often corrects the problem.
  • 80. COMPLICATIONS • Delayed renal bleeding – can occur up to several weeks after injury but – usually occurs within 21 days. • Management – bed rest and hydration. • Persistent bleeding – angiography localize the bleeding vessel - embolization
  • 81. COMPLICATIONS • Perinephric abscess – Rare – persistent urinary extravasation and urinoma are the precursors. • Management – Percutaneous drainage – followed by surgical drainage if necessary.
  • 82. COMPLICATIONS • Hypertension • seldom noted in the early post injury period – The basic mechanisms • (1) renal vascular injury, – leading to stenosis or occlusion of the main renal artery or one of its branches (Goldblatt kidney); • (2) compression of the renal parenchyma with extravasated blood or urine (Page kidney); and
  • 83. • (3) post-trauma arteriovenous fistula. – In these instances, the reninangiotensin axis is stimulated by partial renal ischemia, resulting in hypertension
  • 84. URETERAL INJURIES • "The venial sin is injury to the ureter; the mortal sin is failure of recognition" -Higgins
  • 85. ETIOLOGY • Acute ureteral injury results from:- – external trauma, – open surgery, – laparoscopy, and – endoscopic procedures. • Uncommon:- – intraoperative suture ligation, – sharp incision and transection, – avulsion, – Devascularization • Additionally:- – external violence from high-speed blunt mechanisms and – penetrating stab and gunshot wounds contributes to the overall incidence.
  • 87. • COMPLICATIONS associated with unrecognized or mismanaged ureteral injury:- – urinoma, – abscess, – ureteral stricture, – urinary fistula, and – potential loss of an ipsilateral renal unit.
  • 88. EXTERNAL TRAUMA • ureteral damage after external violence is quite rare, • represent less than 1% of all GU trauma. • penetrating injury - less than 4% and • blunt trauma - less than 1%
  • 89. • Located in the retroperitoneum between the spinal vertebra and major muscle groups, the well-protected ureter is an unlikely target for injury. • Great violence must be inflicted for ureteral damage to occur. • These patients often have significant concomitant injuries and a devastating degree of mortality that approaches one third (Medina et al, 1998). • Associated visceral injury is common, predominantly – small (39% to 65%) and – large (28% to 33%) bowel perforation. – 10% to 28% also have associated renal injuries. – 5% has associated bladder injuries
  • 91. BULLET INJURY • The mechanism of bullet injury to ureter:- – direct transection – disruption of the delicate intramural blood supply and subsequent necrosis. • Due to this “blast effect,” full extent of ureteral loss is sometimes underestimated on initial exploration. • The ureter may appear entirely normal despite the cavitation injury. • Ureteric debridement should be done back to a bleeding edge after bullet injury to remove tissue that may have invisible microvascular damage.
  • 92. BLUNT TRAUMA • Blunt trauma associated with extreme forces causes disruption of ureter at fixed points along its course:- – ureterovesical and, – ureteropelvic junction – m/c • UPJ disruption shows a typical pattern on contrast CT:- – Medial contrast extravasation or – Circumrenal contrast extravasation
  • 93. CT showing right medial extravasation of contrast material in a patient with a renal pelvis laceration
  • 94. SURGICAL INJURY • Any difficult abdomino - pelvic surgical procedure can potentially injure the ureter. • Incidence varies between 0.5% and 10% • procedures contributing to iatrogenic ureteral injuries: – hysterectomy (54%), – colorectal surgery (14%), – ovarian tumor removal (8%), – transabdominal urethropexy (8%), and – abdominal vascular surgery (6%)
  • 95. RISK FACTORS FOR URETERIC INJURIES 1. ANATOMICAL RISK FACTORS. 2. PATHOLOGICAL RISK FACTORS. 3. TECHNICAL RISK FACTORS
  • 96. 1.ANATOMICAL RISK FACTORS: A)THE URETER: • Has close attachment to the peritoneum. • Closely related to female genital tract. • Has variable course. • Not easily seen or palpated.
  • 97. 2.PATHOLOGICAL RISK FACTORS: 1. Congenital anomalies of ureter or Kidney. 2. Ureteric displacement by: Uterine size ≥12 weeks. Prolapse. Tumour{ovarian neoplasm}. Cervical fibroid/Ca. broad ligament swellings(fibroids , incarcirated ovarian tumours or hematomas) 3.Adhesions: Previous pelvic surgery. Endometriosis. PID. Extention of carcinomatous indurations in broad ligaments , post irradiation. 4.Distorted pelvic anatomy.
  • 98. 3.TECHNICAL RISK FACTORS • Massive intraoperative haemorrhage. • Coexistent bladder injury. • Technical difficulties. • Inexperienced surgeon.
  • 99. Vascular procedures • Intraoperative ureteral manipulation – results in subsequent hydronephrosis – common after aortoiliac and aortofemoral bypass surgery – 12% to 20% • Surgical devascularization can result in symptomatic ureteral stenosis, – delayed in presentation by months, – occurring in 1% to 2% of these patients
  • 100. • surgical injuries to the ureter after vascular procedures are not recognized immediately • symptoms of ureteral injury are:- – flank pain, – fever, – ileus, – abdominal distention, and – urinary fistula
  • 101. URETEROARTERIAL FISTULAS • Rare • life-threatening hematuria. • mostly between the ureter and ipsilateral iliac artery, • ETIOLOGY:- – previous pelvic surgery, – radiation therapy, – indwelling ureteral stents, – infection, – primary vascular disease, and – Pregnancy • MANAGEMENT:- – Endovascular stent grafts
  • 103. URETEROSCOPIC INJURY • Kaufman et al, 1984 – first reported ureteral injury after rigid ureteroscopy • Johnson et al, 2004 – ureteroscopic injury is the most common cause of iatrogenic ureteral trauma in modern series
  • 104. • Schuster et al, 2001 – perforation rate of 1% to 5% – 0.2% requires open surgery (Butler et al, 2004) – 5% incidence of delayed stricture occurrence. • Factor responsible:- – persistence of stone basket attempts even after recognition of a ureteral tear.
  • 105. • Factors associated with higher complication rates during ureteroscopy:- – longer surgery times, – treatment of renal calculi, – surgeon inexperience, and – previous irradiation • Factors to protect against ureteral injury:- – smaller ureteroscopes – flexible ureteroscopes – Placement of guide wire
  • 106. American Association for the Surgery of Trauma Organ Injury Severity Scale for the Ureter
  • 107. DIAGNOSIS • HAEMATURIA:- – nonspecific indicator of urologic injury. – Absence of hematuria result from • adynamic ureter, • partially transected ureter or a • complete ureteral transection • Campbell et al, 1992 – 25% to 45% cases after violence do not demonstrate even microscopic hematuria – high index of suspicion is required in cases of potential ureteral injury after penetrating trauma.
  • 108. • INTRAOPERATIVELY:- – trajectory of the knife or missile - carefully examined during laparotomy – ureteral exploration - all cases of potential injury. – intraoperative inspection of retroperitoneum most important means of diagnosing ureteral injury due to penetrating trauma
  • 109. • Methylene Blue:- – Suspected ureteral or renal pelvis injury – 1 to 2 mL of methylene blue dye – directly injected into the renal pelvis – with a 27-gauge needle to confirm the diagnosis.
  • 110. IMAGING STUDIES • Excretory Urography:- – Ureteral injuries - unlike renal injuries - difficult to detect – IVP is often unhelpful, – proving nondiagnostic 33% to 100% of the time – intraoperative one-shot pyelography still recommend • to detect ureteral injuries and • assess the functional status of the contralateral system.
  • 112. • CT scan:- – Ureteral injuries - difficult - diagnose on CT. – Delayed images - must – Findings:- • medial extravasation of contrast material or • nonopacification of the ipsilateral ureter
  • 113. Retrograde ureterograms:- • most sensitive radiographic test for ureteral injury, • used in some centers as a primary diagnostic technique • delineate the extent of ureteral injury seen on CT scan or IVP • Advantage:- – allows simultaneous placement of a ureteral stent .
  • 114. MANAGEMENT • Principles of URETERIC INJURY REPAIR : 1. Mobilize the injured ureter - sparing the adventitia widely - not to devascularize the ureter. 2. Debride the ureter liberally until the edges bleed, 3. Repair ureters with spatulated, tension-free, stented watertight anastomosis
  • 115. 4. Retroperitonealize the ureteral repair by closing peritoneum over it. 5. With severely injured ureters, blast effect, concomitant vascular surgery, and other complex cases, • consider omental interposition to isolate the repair.
  • 116. Identification Courses vary among normal individuals* * Sampson JA, John Hopkins Med Bull 1904;156:72 - Peristalsis - Pale glistening appearance -Longitudinal vessels on the surface -Unique "snap" feeling when pressed between 2 fingers
  • 117. • Ureteroureterostomy – A/K/A end-to-end repair – Used in injuries to the upper two thirds of ureter. – success rate 90% (Carlton et al, 1971). – Complications • urine leakage - 10% to 24% • Other:- – abscess and – fistula. • Chronic complications:- – ureteral stenosis - 5% to 12%
  • 118. • STENTING:- – Minor ureteral contusions - Stent placement. – Caution • minor-appearing ureteral contusions may stricture later • break down secondary to unappreciated microvascular damage – When in doubt • the injured portion of the ureter should be debrided and • Ureteroureterostomy used to repair the injury.
  • 119. STENTING  Insert a ureteral stent through the anastomosis before closure. Advantages : 1. Maintenance of a straight ureter with a constant caliber during early healing, 2. The presence of a conduit for urine during healing, 3. Prevention of urinary extravasation, 4. Maintenance of urinary diversion, 5. Easy removal
  • 120. MANAGEMENT OPTIONS FOR URETERAL INJURIES AT DIFFERENT LEVELS
  • 121. UPPER URETERAL INJURIES • Ureteroureterostomy:- – Ureteral avulsion from the renal pelvis, or – very proximal ureteral injury, – managed by • reimplantation of the ureter directly into the renal pelvis. • Both – open and laparoscopic
  • 122. UPPER URETERAL INJURIES • Bowel Interposition:- – long segment of ureter is destroyed, – ureteral conduit out of ileum is created to drain the urine, – Success rates:- • 81% - Boxer et al, 1979; • 100% - Bonfig et al, 2004. – Long-term complications • 3% anastomotic stricture and • 6% fistula rate
  • 123. UPPER URETERAL INJURIES • MONTI PROCEDURE:- • short segments of bowel • formed into a long thin tube for ureteral reconstruction • Ileal interposition is not suggested for acute repair of ureteral injury but rather would be used in delayed or staged repairs.
  • 124. Ileal transposition (Syn- Uretero-ileo-neo-cystostomy/ Uretero-entero-neo-cystostomy) • Healthy, viable segment of distal ileum with vascular arcade is ''collected'' after side- to-side stapled anastomosis • Proximal segment of ileal loop is opened • Ureter is spatulated • Full thickness of ureter is pulled through a hole made in the anti-mesenteric border of the ileum and sutured over a stent • Sero-muscular suturing is done
  • 125. • Distal end of the ileal loop is opened and puled over the stent through an incision (over bladder dome) and mucosal suturing done • Seromuscular suturing done • "Ileal conduit" is sutured to psoas fascia to reduce tension on the anastomosis due to gravity • Bladder drainage for 10 days
  • 126. MIDURETERAL INJURIES • Ureteroureterostomy • Transureteroureterostomy:- – rarely used – performed as a secondary or delayed procedure. – Success rate – • Adults - 90% to 97% • Pediatric - 70% – Technique – • involves bringing the injured ureter across the midline and • anastomosing it end to side into the uninjured ureter
  • 128. LOWER URETERAL INJURIES • Ureteroneocystostomy:- – used to repair distal ureteral injuries – occur very close to the bladder – Principles:- • creation of submucosal tunnel for nonrefluxing ureter • tunnel length three times longer than the width of ureter. • new ureteral orifice is constructed with the use of interrupted sutures in a watertight and nonobstructing fashion. • stented.
  • 129. LOWER URETERAL INJURIES • Psoas Bladder Hitch:- – injuries to the lower third of the ureter – high success rate - 95% to 100%
  • 131. LOWER URETERAL INJURIES • Boari Flap:- – Injuries to the lower two thirds of the ureter – with long ureteral defects – too long to be bridged by bringing the bladder up in the psoas hitch procedure – Technique:- • a pedicle of bladder is swung cephalad and tubularized to bridge the gap to the injured ureter.
  • 133. DAMAGE CONTROL • Injured ureter is managed by deferring the definitive treatment • Useful:- – too unstable patient – Unable to tolerate the operative time required to complete the repair.
  • 134. DAMAGE CONTROL • Options:- (1) do nothing & plan a reoperation when the patient is more stable, usually within 24 hours; (2) place a ureteral stent and do nothing else (3) exteriorize the ureter; or (4) tie off the ureter and plan percutaneous nephrostomy
  • 135. SURGICAL INJURY • Ligation:- – treated by removal of ligature and – observation of the ureter for viability. – If viability is doubtful, • ureteroureterostomy or • ureteral reimplantation
  • 136. URETEROSCOPY INJURY • Avulsion:- – treated in same manner as ureteral injuries after open or laparoscopic surgery • Perforation:- – perforation can be treated by stenting – usually with no subsequent complications
  • 140. Guideline Statements Approved by the AUA Board of Directors April 2014
  • 141. Renal trauma • 1. Clinicians should perform diagnostic imaging with intravenous (IV) contrast enhanced computed tomography (CT) in stable blunt trauma patients with gross hematuria or microscopic hematuria and systolic blood pressure < 90mmHG.
  • 142. • 2. Clinicians should perform diagnostic imaging with IV contrast enhanced CT in stable trauma patients with mechanism of injury or physical exam findings concerning for renal injury (e.g., rapid deceleration, significant blow to flank, rib fracture, significant flank ecchymosis, penetrating injury of abdomen, flank, or lower chest).
  • 143. • 3. Clinicians should perform IV contrast enhanced abdominal/pelvic CT with immediate and delayed images when there is suspicion of renal injury.
  • 144. • 4. Clinicians should use non - invasive management strategies in hemodynamically stable patients with renal injury.
  • 145. • 5. The surgical team must perform immediate intervention (surgery or angioembolization in selected situations) in hemodynamically unstable patients with no or transient response to resuscitation.
  • 146. • 6. Clinicians may initially observe patients with renal parenchymal injury and urinary extravasation.
  • 147. • 7. Clinicians should perform follow - up CT imaging for renal trauma patients • having either (a) deep lacerations (AAST Grade IV - V) or (b) clinical signs of complications (e.g., fever, worsening flank pain, ongoing blood loss, abdominal distention).
  • 148. • 8. Clinicians should perform urinary drainage in the presence of complications such as enlarging urinoma, fever, increasing pain, ileus, fistula or infection. (Recommendation; Evidence Strength: Grade C) Drainage should be achieved via ureteral stent and may be augmented by percutaneous urinoma drain, percutaneous nephrostomy or both.
  • 149. Ureteral Trauma • 9a. Clinicians should perform IV contrast enhanced abdominal/pelvic CT with delayed imaging (urogram) for stable trauma patients with suspected ureteral injuries.
  • 150. • 9b. Clinicians should directly inspect the ureters during laparotomy in patients with suspected ureteral injury who have not had preoperative imaging.
  • 151. • 10a. Surgeons should repair traumatic ureteral lacerations at the time of laparotomy in stable patients.
  • 152. • 10b. Surgeons may manage ureteral injuries in unstable patients with temporary urinary drainage followed by delayed definitive management.
  • 153. • 10c. Surgeons should manage traumatic ureteral contusions at the time of laparotomy with ureteral stenting or resection and primary repair depending on ureteral viability and clinical scenario.
  • 154. • 11a. Surgeons should attempt ureteral stent placement in patients with incomplete ureteral injuries diagnosed postoperatively or in a delayed setting.
  • 155. • 11b. Surgeons should perform percutaneous nephrostomy with delayed repair as needed in patients when stent placement is unsuccessful or not possible.
  • 156. • 12a. Surgeons should repair ureteral injuries located proximal to the iliac vessels with primary repair over a ureteral stent, when possible.
  • 157. • 12b. Surgeons should repair ureteral injuries located distal to the iliac vessels with ureteral reimplantation or primary repair over a ureteral stent, when possible.
  • 158. • 13a. Surgeons should manage endoscopic ureteral injuries with a ureteral stent and/or percutaneous nephrostomy tube, when possible.
  • 159. • 13b. Surgeons may manage endoscopic ureteral injuries with open repair when endoscopic or percutaneous procedures are not possible or fail to adequately divert the urine.

Notas do Editor

  1. WHEN THE KIDNEY IS THE ONLY ORGAN DAMAGED THE INJURY IS MINOR IN AROUND 98%CASES
  2. Mechanism renal injuries; Lt. direct blow to abdomen แรงกระทำกระจายจาก renal hilum Rt, fall frm height (contracoup) ภาพแสดง direction forces กระทำต่อไตจากด้านบน tear of renal pedicle With a direct injury the kidney is either crushed between the anterior end of the 12th rib and the lumbar spine-such as in sporting injuries-or between an external force applied to the abdomen anteriorly just below the rib cage and the paravertebral muscles-such as in run over accidents and injuries caused by seat belts and steering columns. Indirect injury occurs when a deceleration force is applied to the renal pedicle (as a result of falling from a height and landing on the buttocks). Such injuries can tear the major renal vessels or rupture the ureter at the pelviureteric junction.
  3. Pain : localized to one flank area or over the abdomen Gross or microscopic hematuria Ecchymosis in the flank or upper quadrants of the abdomen Lower ribs or transverse process fracture Palpable mass : large retroperitoneal hematoma or urinary extravasation Generalized peritonitis
  4. Severe abdominal and flank ecchymosis with potential urological injury (caused by a seat belt).
  5. A Retroperitoneal incision over Aorta medial to Inf. Mesenteric B Anatomic relationship of renal vvs. C retroperitoneal incision lateral to the colon
  6. In ½ OF THE cases URETERIC INJURy is not identified at the time of primary injury during surgery
  7. These stents have a J memory curve on each end to prevent their migration in the postoperative period. After 3–4 weeks of healing, stents can be endoscopically removed from the bladder.
  8. These criteria should allow early and accurate detection and staging of significant renal injuries. Advantages of CT outweigh the risks, which include contrast related complications, radiation exposure, and the dangers of transporting a patient away from the resuscitation environment into the CT scanner
  9. Up to 34% of multisystem trauma patients may have renal injury despite absence of hematuria or hemodynamic instability.
  10. o elucidate both the location of renal lacerations and the presence of contrast extravasation from collecting system injuries.
  11. avoids unnecessary surgery, decreases unnecessary nephrectomy, and preserves renal function Patients initially managed noninvasively may still require surgical, endoscopic, or angiographic treatments at a later time, especially those with higher grade injuries. Although devitalized parenchyma has been suggested as a risk factor for development of septic complications, evidence supporting intervention for this radiographic finding is inconclusive.
  12. Hemodynamic instability despite resuscitation suggests uncontrolled and ongoing bleeding. Surgeons may perform one-shot IVP prior to renal exploration to document function of the contralateral, uninjured kidney using 2 mL/kg IV contrast and a single delayed image at 10-15 minutes. The benefit of prior vascular control in the modern series examined in this Guideline are inconclusive,46, 47 although older studies suggest that it is beneficial. Nephrectomy is a frequent result when hemodynamically unstable patients undergo surgical exploration.48, 49 Selected patients with bleeding from segmental renal vessels may benefit from angioembolization as an effective yet minimally invasive treatment to control bleeding.
  13. Parenchymal collecting system injuries often resolve spontaneously. A period of observation without intervention is advocated in stable patients where renal pelvis or proximal ureteral injury is not suspected, preventing the risk of injury during stent placement, risk of anesthesia, or risk of retained stent through lack of follow-up.
  14. Follow-up CT imaging (after 48 hours) is prudent in patients with deep renal injuries (AAST Grade IV-V) because these are prone to developing troublesome complications such as urinoma or hemorrhage Periodic monitoring of blood pressure up to a year after the injury may uncover the rare instances of post-injury renovascular hypertension.
  15. In stable patients not proceeding directly to exploratory laparotomy, IV contrast enhanced abdominal/pelvic CT with 10 minute delayed images should be obtained to evaluate for ureteral injury. Findings suggestive of ureteral injury include contrast extravasation, ipsilateral delayed pyelogram, ipsilateral hydronephrosis, and lack of contrast in the ureter distal to the suspected injury.
  16. Adjunctive maneuvers to identify ureteral injuries include careful ipsilateral ureteral mobilization and/or IV or intraureteral injectable dyes such as methylene blue or indigo carmine. Retrograde pyelography may be performed in equivocal cases when possible. Intraoperative single-shot IVP cannot reliably exclude ureteral injury and should not be used solely for this purpose.
  17. Ureteral repair should be performed at the time of initial laparotomy, when possible, though immediate repair may not be appropriate in unstable, complex polytrauma patients.
  18. n damage control settings when immediate ureteral repair is not possible at the time of initial laparotomy, urinary extravasation can be prevented with ureteral ligation followed by percutaneous nephrostomy tube placement or with an externalized ureteral catheter secured to the proximal end of the ureteral defect. Definitive repair of the injury should be performed when the patient's clinical situation has improved/stabilized.
  19. Ureteral contusion is not uncommon in the context of a gunshot wound with blast injury; complications may include delayed ureteral stricture and/or overt ureteral necrosis with urinary extravasation. Thus, when identified during laparotomy, intact but contused ureters should be primarily managed with ureteral stenting; resection with primary repair may be performed in selected instances, particularly after gunshot wounds, depending on the severity of the contusion and the viability of local tissues.
  20. When an incomplete ureteral injury is at first unrecognized or presents in a delayed fashion, retrograde ureteral imaging with ureteral stent placement should be performed initially.75-81 Immediate repair can be considered in certain clinical situations if the injury is recognized within one week (e.g., injury located near a surgically closed viscus, such as bowel or vagina, or if the patient is being re-explored for other reasons).
  21. When the proximal ureter is completely transected or otherwise cannot be cannulated in a retrograde fashion, or if patient instability precludes attempts at retrograde treatment, a percutaneous nephrostomy tube should be placed. If nephrostomy alone does not adequately control the urine leak, options then include placement of a periureteral drain or immediate open ureteral repair