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Genitourinary Tract Genitourinary Tract InjuriesInjuriesInjuriesInjuries

66thth Nordic CourseNordic Course

Scott D. Steenburg, MDAssistant Professor

University of Maryland Department of RadiologyDivision of Trauma and Emergency Radiology

R Adams Cowley Shock Trauma Center

ObjectivesObjectives• Role of imaging in evaluation of 

it i tgenitourinary trauma • Spectrum of GU injuries• Relevance of imaging findings in determining management

• Focus on MDCT

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Genitourinary TractGenitourinary Tract• Adrenal glands• Kidneys• Ureters• Bladder• UrethraUrethra

Genitourinary Tract TraumaGenitourinary Tract Trauma• 10% of all blunt abdominal trauma• Trend towards conservative management

• Imaging directs management and further investigation

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Adrenal GlandsAdrenal Glands• Incidence up to 4% of blunt trauma• Unilateral R>>L>bilateral• Unilateral, R>>L>bilateral• Rarely isolated• Adjacent injuries common

– Esp liver• Unilateral adrenal injuries of little clinicalUnilateral adrenal injuries of little clinical significance

• Bilateral injuries rarely cause adrenal  insufficiency

Adrenal GlandsAdrenal Glands• CT imaging findings:

il d l h i– Expansile, round or oval hyperattenuating hematoma

– Irregularity or obliteration by hemorrhage, 

–Periadrenal fat stranding

Enlargement due to edema or contusion– Enlargement due to edema or contusion

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Adrenal Hematoma

Adrenal Hemorrhage / Bare Area Contusion

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Adrenal injury with active hemorrhage

Renal TraumaRenal Trauma• 3‐10% of blunt trauma patients• Blunt trauma 80‐90%

–Parenchymal–Collecting system–Vascular

• 95‐98% of renal injuries managed conservatively

Alonso RC et al. Kidney in Danger: CT Findings of Blunt and Penetrating Renal Trauma. RadioGraphics 2009; 29:2033–2053Ramchandani and Buckler. Imaging of Genitourinary Trauma. AJR 2009; 192:1514–1523

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Renal Trauma Renal Trauma –– HematuriaHematuria??

• Hematuria often absentb f l h l–Absent in 10‐25% of renal parenchymal 

injuries–Absent in 25‐50% of patients with ureteropelvic juntion injuries

–Ureteral tear vascular pedicle injury or–Ureteral tear, vascular pedicle injury, or ureteropelvic junction avulsion

Alonso RC et al. Kidney in Danger: CT Findings of Blunt and Penetrating Renal Trauma. RadioGraphics 2009; 29:2033–2053Kawashima A, Sandler CM, Corl FM, et al. Imaging of renal trauma: a comprehensive review. Radiographics 2001;21(3):557–74.Ramchandani and Buckler. Imaging of Genitourinary Trauma. AJR 2009; 192:1514–1523

Renal Trauma Renal Trauma –– HematuriaHematuria??

• No correlation between degree ofNo correlation between degree of hematuria and extent of renal injury

Alonso RC et al. Kidney in Danger: CT Findings of Blunt and Penetrating Renal Trauma. RadioGraphics 2009; 29:2033–2053Kawashima A, Sandler CM, Corl FM, et al. Imaging of renal trauma: a comprehensive review. Radiographics 2001;21(3):557–74Ramchandani and Buckler. Imaging of Genitourinary Trauma. AJR 2009; 192:1514–1523

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Renal Trauma:  Renal Trauma:  Imaging ProtocolsImaging Protocols

–MDCT primary imaging modality•Anatomy and function

–Multi‐phase acquisition•Arterial phaseArterial phase•Parenchymal phase•Delayed phase

Renal TraumaRenal Trauma

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Renal TraumaRenal Trauma• Grade I injuries

• 75‐85% of all renal injuries

• Contusions

• Non‐expanding subcapsular hematomas

Alonso RC et al. Kidney in Danger: CT Findings of Blunt and Penetrating Renal Trauma. RadioGraphics 2009; 29:2033–2053Ramchandani and Buckler. Imaging of Genitourinary Trauma. AJR 2009; 192:1514–1523

Renal Contusion / Laceration

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• Grade II injuries– Non‐expanding perinephric hematomas confined

Renal TraumaRenal Trauma

Non expanding perinephric hematomas confined to the retroperitoneum

– Superficial cortical lacerations <1 cm in depth 

• Grade III injuries– Lacerations deeper than 1 cm– Extend into the medullaExtend into the medulla. 

• Grade II and III lacerations spare the collecting system

Alonso RC et al. Kidney in Danger: CT Findings of Blunt and Penetrating Renal Trauma. RadioGraphics 2009; 29:2033–2053Ramchandani and Buckler. Imaging of Genitourinary Trauma. AJR 2009; 192:1514–1523

Subcapsular HematomasGrade II

Grade III

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• Grade IV injuriesL ti t di th h t

Renal TraumaRenal Trauma

– Lacerations extending through cortex, medulla and into the collecting system

– Injuries involving the main renal artery or vein with contained hemorrhage

– Segmental infarctions without associated– Segmental infarctions without associated lacerations

Alonso RC et al. Kidney in Danger: CT Findings of Blunt and Penetrating Renal Trauma. RadioGraphics 2009; 29:2033–2053Ramchandani and Buckler. Imaging of Genitourinary Trauma. AJR 2009; 192:1514–1523

• Renal infarctionSt t hi f th l t d

Renal TraumaRenal Trauma

– Stretching of the renal artery produces an intimal tear or dissection

–CT findings:

• Segmental = peripheral, well‐defined, wedge‐shaped non‐enhancingwedge‐shaped, non‐enhancing

Alonso RC et al. Kidney in Danger: CT Findings of Blunt and Penetrating Renal Trauma. RadioGraphics 2009; 29:2033–2053Ramchandani and Buckler. Imaging of Genitourinary Trauma. AJR 2009; 192:1514–1523

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Kawashima A, et al. Imaging of Renal Trauma: A Comprehensive Review. RadioGraphics 2001; 21:557–574

• Renal infarctionM t t l l i f t h l

Renal TraumaRenal Trauma

–Most segmental renal infarcts heal spontaneously to form scars

– Infarcts >50% may need surgical debridement

Alonso RC et al. Kidney in Danger: CT Findings of Blunt and Penetrating Renal Trauma. RadioGraphics 2009; 29:2033–2053Ramchandani and Buckler. Imaging of Genitourinary Trauma. AJR 2009; 192:1514–1523

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Segmental Renal Infarct

Segmental Renal Infarct

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Multi-focal Segmental Renal Infarcts

• Grade V injuriesMost severe type of renal injury

Renal TraumaRenal Trauma

– Most severe type of renal injury

– Shattered kidney

– Partial tears or complete laceration (avulsion) of the ureteropelvic junction

– Thrombosis of main renal artery or vein with d l i i f h kiddevascularization of the kidney

Alonso RC et al. Kidney in Danger: CT Findings of Blunt and Penetrating Renal Trauma. RadioGraphics 2009; 29:2033–2053Ramchandani and Buckler. Imaging of Genitourinary Trauma. AJR 2009; 192:1514–1523

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Right renal artery avulsion

Right Infarct, Left Contusion

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Right renal artery injury, renal infarct

• Shattered KidneyMultiple fragments

Renal TraumaRenal Trauma

– Multiple fragments

– 1 or more devitalized areas regions

– Excreted contrast leak

– Injuries to the collecting system

– Severe hemorrhage

– Active arterial bleeding

Alonso RC et al. Kidney in Danger: CT Findings of Blunt and Penetrating Renal Trauma. RadioGraphics 2009; 29:2033–2053Ramchandani and Buckler. Imaging of Genitourinary Trauma. AJR 2009; 192:1514–1523

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Shattered Kidney

Grade V Renal Injury with active bleeding

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Renal vein pseudoaneurysm with active bleeding

Left vein injury with active bleeding

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UreterUreter InjuriesInjuries• Ureteropelvic junction• Ureter• Ureteropelvic junction

Alonso RC et al. Kidney in Danger: CT Findings of Blunt and Penetrating Renal Trauma. RadioGraphics 2009; 29:2033–2053Ramchandani and Buckler. Imaging of Genitourinary Trauma. AJR 2009; 192:1514–1523

UreterUreter InjuriesInjuries• Ureteropelvic junction injuries

–Shearing stress at the renal pelvis• Ureter is retroperitoneal with only fixation points at UPJ and UVJ

• Hematuria absent in 25 50%• Hematuria absent in 25‐50%

Alonso RC et al. Kidney in Danger: CT Findings of Blunt and Penetrating Renal Trauma. RadioGraphics 2009; 29:2033–2053Ramchandani and Buckler. Imaging of Genitourinary Trauma. AJR 2009; 192:1514–1523

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UreterUreter InjuriesInjuries• Delayed phase essential!

–>5min

• Leak on arterial and parenchymal phases often absent

Alonso RC et al. Kidney in Danger: CT Findings of Blunt and Penetrating Renal Trauma. RadioGraphics 2009; 29:2033–2053Ramchandani and Buckler. Imaging of Genitourinary Trauma. AJR 2009; 192:1514–1523

UreterUreter InjuriesInjuries• Partial laceration vs transection

–Partial laceration = leak of excreted contrast with opacified distal ureter

–Transection = leak of excreted contrast with unopacified distal ureter

Alonso RC et al. Kidney in Danger: CT Findings of Blunt and Penetrating Renal Trauma. RadioGraphics 2009; 29:2033–2053Ramchandani and Buckler. Imaging of Genitourinary Trauma. AJR 2009; 192:1514–1523

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UreterUreter InjuriesInjuries• Partial laceration vs transection

–Partial laceration:• Treated conservatively or with stent placement

–Complete transection:• Usually requires surgical repair

Alonso RC et al. Kidney in Danger: CT Findings of Blunt and Penetrating Renal Trauma. RadioGraphics 2009; 29:2033–2053Ramchandani and Buckler. Imaging of Genitourinary Trauma. AJR 2009; 192:1514–1523

UreterUreter InjuriesInjuries• Urinary extravasation alone is not an indication for surgery

–Can spontaneously resolve –Up to 87% of patientsF ll i i d d• Follow‐up imaging recommended

Knudson MM and Maull KI. Nonoperative management of solid organ injuries: past, present and future. Surg Clin North Am 1999; 79:1357–1367. Alonso RC et al. Kidney in Danger: CT Findings of Blunt and Penetrating Renal Trauma. RadioGraphics 2009; 29:2033–2053Ramchandani and Buckler. Imaging of Genitourinary Trauma. AJR 2009; 192:1514–1523

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Uretero‐Pelvic Junction Laceration

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Proximal Ureter Laceration

Goals of Management?• Minimize hemorrhage

• Maintain urinary flow without obstruction – Preserve renal function

• Prevent urine leak– Decreases risk of local and systemic infection

Alonso RC et al. Kidney in Danger: CT Findings of Blunt and Penetrating Renal Trauma. RadioGraphics 2009; 29:2033–2053Ramchandani and Buckler. Imaging of Genitourinary Trauma. AJR 2009; 192:1514–1523