Urotrauma: AUA Guideline Allen F. Morey, Steve Brandes, Daniel David Dugi III, John H. Armstrong, Benjamin N. Breyer, Joshua A. Broghammer, Bradley A. Erickson, Jeff Holzbeierlein, Steven J. Hudak, Jeffrey H. Pruitt, James T. Reston, Richard A. Santucci, Thomas G. Smith III and Hunter Wessells From the American Urological Assocation Education and Research, Inc., Linthicum, Maryland Purpose: The authors of this guideline reviewed the urologic trauma literature Abbreviations to guide clinicians in the appropriate methods of evaluation and management and Acronyms of genitourinary injuries. ¼ Materials and Methods: AAST American Association for A systematic review of the literature using the the Surgery of Trauma MEDLINEÒ and EMBASE databases (search dates 1/1/90-9/19/12) was con- CT ¼ computerized tomography ducted to identify peer-reviewed publications relevant to urotrauma. The review yielded an evidence base of 372 studies after application of inclusion/exclusion ICU ¼ intensive care unit criteria. These publications were used to inform the statements presented in the IV ¼ intravenous guideline as Standards, Recommendations or Options. When sufficient evidence IVP ¼ intravenous pyelogram existed, the body of evidence for a particular treatment was assigned a strength MRI ¼ magnetic resonance rating of A (high), B (moderate) or C (low). In the absence of sufficient evidence, imaging additional information is provided as Clinical Principles and Expert Opinions. ORIF ¼ open reduction internal Results: Guideline statements were created to inform clinicians on the initial fixation observation, evaluation and subsequent management of renal, ureteral, bladder, PFUI ¼ pelvic fracture urethral urethral and genital traumatic injuries. injury Conclusions: Genitourinary organ salvage has become increasingly possible as a PR ¼ primary realignment result of advances in imaging, minimally invasive techniques, and reconstructive SP ¼ suprapubic surgery. As the field of genitourinary reconstruction continues to evolve, clini- SPT ¼ suprapubic tube cians must strive to approach clinical problems in a creative, multidisciplinary, evidence-based manner to ensure optimal outcomes. The complete guideline is available at http:// www.auanet.org/education/guidelines/urotrauma. Key Words: urotrauma, injury cfm. This document is being printed as submitted independent of editorial or peer review by the Editors of The Journal of UrologyÒ. THE Panel’s purpose is to review the urethral, and genital trauma. Guide- existing literature pertaining to the line statements were formed based on acute care of urologic injuries in an this literature review. effort to develop effective guidelines The AUA nomenclature system for appropriate diagnosis and inter- explicitly links statement type to vention strategies in the setting body of evidence strength and the of urotrauma. Panel’s judgment regarding the bal- ance between benefits and risks/ burdens.1 For a complete discussion METHODOLOGY of the methodology and evidence A comprehensive search of the liter- grading, please refer to the un- ature targeted the five main uro- abridged guideline available at http:// trauma topics within the scope of this www.auanet.org/education/guidelines/ guideline: renal, ureteral, bladder, urotrauma.cfm. 0022-5347/14/1922-0327/0 http://dx.doi.org/10.1016/j.juro.2014.05.004 ® THE JOURNAL OF UROLOGY Vol. 192, 327-335, August 2014 www.jurology.com j 327 © 2014 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION AND RESEARCH,INC. Printed in U.S.A. 328 UROTRAUMA BACKGROUND phases is preferred in order to elucidate both the Definition location of renal lacerations and the presence of contrast extravasation from collecting system in- Trauma refers to injury caused by external force juries. Standard intravenous pyelogram may be used from a variety of mechanisms, including traffic- or in rare cases where CT is not available, but is infe- transportation-related injuries, falls, assault (e.g., rior. Ultrasound may be used in children, although blunt weapon, stabbing, gunshot), explosions, etc. CT is preferred. An intraoperative one-shot IVP may Prevalence be used to confirm that a contralateral functioning kidney is present in rare cases where the patient is Traumatic injuries are the leading cause of death in taken to the operating room without a CT scan. the United States for people ages 1-44 years, and a 4. Clinicians should use non-invasive man- significant cause of morbidity and loss of productive agement strategies in hemodynamically stable life across all ages.2 Worldwide, traumatic injuries patients with renal injury. (Standard; Evi- are the sixth leading cause of death and the fifth dence Strength: Grade B) leading cause of moderate and severe disability.3 Stable patients are defined as those who do not The kidneys are the most commonly injured geni- have vital signs consistent with shock and show tourinary organ. Civilian renal injury occurs in up stable serial hematocrit values over time. Nonin- to 5% of trauma victims,4,5 and accounts for 24% of vasive management of renal injury, which may traumatic abdominal solid organ injuries.6 consist of close hemodynamic monitoring, bed rest, ICU admission and blood transfusion, avoids un- GUIDELINE STATEMENTS necessary surgery, decreases unnecessary nephrec- tomy, and preserves renal function. Renal Trauma 5. The surgical team must perform immedi- 1. Clinicians should perform diagnostic imag- ate intervention (surgery or angioembolization ing with intravenous contrast enhanced in selected situations) in hemodynamically computerized tomography in stable blunt unstable patients with no or transient response trauma patients with gross hematuria or to resuscitation. (Standard; Evidence Strength: microscopic hematuria and systolic blood Grade B) pressure < 90 mm HG. (Standard; Evidence Hemodynamic instability despite resuscitation Strength: Grade B) suggests uncontrolled and ongoing bleeding. Imme- These criteria should allow early and accurate diate intervention (either open surgery or angioem- detection and staging of significant renal injuries. bolization) is warranted for unstable patients to Advantages of CT outweigh the risks, which include limit the need for future transfusion and prevent contrast related complications, radiation exposure, life-threatening complications. The goal of operative and the dangers of transporting a patient away from exploration is to control bleeding first, repair the the resuscitation environment. kidney (when possible), and establish perirenal 2. Clinicians should perform diagnostic im- drainage. Nephrectomy is a frequent result when aging with IV contrast enhanced CT in stable hemodynamically unstable patients undergo surgi- trauma patients with mechanism of injury or cal exploration. physical exam findings concerning for renal Selected patients with bleeding from segmental injury (e.g., rapid deceleration, significant renal vessels may benefit from angioembolization as blow to flank, rib fracture, significant flank a minimally invasive treatment to control bleeding. ecchymosis, penetrating injury of abdomen, Patients who are hemodynamically unstable despite flank, or lower chest). (Recommendation; Evi- active resuscitation should be taken to the operating dence Strength: Grade C) room rather than angiography. Up to 34% of multisystem trauma patients may 6. Clinicians may initially observe patients have renal injury despite absence of hematuria or with renal parenchymal injury and urinary hemodynamic instability.7 A lack of these findings extravasation. (Clinical Principle) should not preclude imaging if clinicians suspect Parenchymal collecting system injuries often renal injury based on physical findings, associated resolve spontaneously. A period of observation abdominal injuries, or mechanism of injury. without intervention is advocated in stable patients 3. Clinicians should perform IV contrast where renal pelvis or proximal ureteral injury is enhanced abdominal/pelvic CT with immedi- not suspected. When renal pelvis or proximal ure- ate and delayed images when there is suspi- teral avulsion is suspected, prompt intervention cion of renal injury. (Clinical Principle) is warranted. CT scan of the abdomen and pelvis, using IV 7. Clinicians should perform follow-up CT contrast with immediate and delayed (10 minute) imaging for renal trauma patients having UROTRAUMA 329 either (a) deep lacerations (AAST Grade IV-V) directly to laparotomy without adequate radio- or (b) clinical signs of complications (e.g., graphic staging. Adjunctive maneuvers to identify fever, worsening flank pain, ongoing blood ureteral injuries include careful ipsilateral ureteral loss, abdominal distention). (Recommenda- mobilization and/or IV or intraureteral injectable tion; Evidence Strength: Grade C) dyes, such as methylene blue or indigo carmine. Follow-up CT imaging (after 48 hours) is prudent Retrograde pyelography may be performed in in patients with deep renal injuries (AAST Grade equivocal cases when possible. IV-V) because these are prone to developing trou- 10a. Surgeons should repair traumatic ure- blesome complications, such as urinoma or hemor- teral lacerations at the time of laparotomy in rhage. AAST Grade I-III injuries have a low risk of stable patients. (Recommendation; Evidence complications and rarely require intervention;8 Strength: Grade C) routine follow-up CT imaging is not advised for Ureteral repair should be performed at the time these injuries. of initial laparotomy, when possible, though imme- 8. Clinicians should perform urinary