• Imaging of suspected ureteral injuries should be performed using the most expeditious technique available (Fig. 7.6b).
• UPJ injuries are reliably demonstrated using an intravenous pyelogram. However, CT urography (CTU) at the excretory phase is an effective technique in evaluating the ureter.
• Contrast extravasation around the kidney defines a high ureteral laceration on imaging studies. This extravasation is often more profound medially.
• Contrast may be seen in the ureter with a partial laceration, however no contrast enters the ureter following a complete tear.
• If contrast extravasation is extensive, distinguishing contrast in the ureter from extravasate may be difficult.
(a) (b)
Figure 7.6 (a) Injured upper third of ureter secondary to bullet, which caused quadriplegia in a 21-year-old male. CT performed several days after injury shows development of an urinoma (U) around a ureteral stent (arrow). Arrowhead points to bullet lodged in the spine. (b) Progressive injection of contrast through the nephrostomy tube shows contrast extravasating through the rupture of the upper third of the left ureter. A stent is seen within the lumen of the ureter. A pig tail catheter draining the urinoma is shown.
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• In cases of non-diagnostic IVP or CT, a retrograde or antegrade pyelogram may be performed to elucidate ureteral integrity.
Clinical management
• Ureteral injuries can be classified by location (upper, middle or lower), timing of presen- tation (immediate or delayed), cause (blunt or penetrating), and extent of injury.
• Injuries that are non-penetrating or minor may require no intervention.
• Controversy exists regarding the most appropriate management of ureteral injuries fol- lowing penetrating trauma.
• Generally, primary repair of penetrating injuries is preferable, however the effect of concomitant abdominal injuries may preclude this.
• Surgical repair attempted more than 7 days following the injury may be difficult due to a marked inflammatory response.
• A retrograde or antegrade ureteral stent or percutaneous nephrostomy tube may be placed (Fig. 7.6c).
• In some cases, urinary diversion by nephrostomy or stent placement may be sufficient.
• Strictures can be managed endoscopically through balloon dilatation or endoureterotomy.
• Approximately 6–8 weeks are necessary prior to open surgical repair to allow for adequate healing and resolution of inflammation.
7.5 Bladder trauma
Introduction
• Bladder injuries may occur from penetrating or blunt trauma.
• Major bladder injury occurs in approximately 10% of patients with pelvic fractures.
• The susceptibility of the bladder to injury increases with its degree of distention.
◦ In children, the bladder is intra-abdominal and therefore more vulnerable to injury at any capacity.
Clinical presentation
• Gross hematuria occurs in over 95% of bladder injuries.
• Other presentations may include microscopic hematuria, suprapubic tenderness, or urinary retention.
Classification of bladder injuries
• Type 1 – Bladder contusion
◦ represents an incomplete tear of the bladder mucosa, and is generally conceded to be the most common type of bladder injury following blunt trauma (Fig. 7.7a).
(a) (b)
(c) (d)
Figure 7.7 (a) Cystogram shows bladder contusion (arrows) following blunt trauma. (b) Cystogram shows contrast leaking into the peritoneal cavity secondary to intraperitoneal rupture of the bladder. (c) Cystogram shows extraperitoneal extravasation of contrast on left side. (d) CT shows extraperitoneal extravasation of contrast surrounding the bladder (B) and running along the lateral gutter into the anterior abdominal wall.
• Type 2 – Intraperitoneal rupture
◦ accounts for approximately one-third of major bladder injuries, and approximately 25%
of cases are not associated with a pelvic fracture (Fig. 7.7b).
• Type 3 – Interstitial bladder injury
◦ is a rare injury representing an incomplete laceration of the bladder wall.
• Type 4 – Extraperitoneal rupture
◦ is almost always seen in conjunction with pelvic fracture or diastasis of the pubic symphysis, and represents approximately 60% of major bladder injuries.
• Type 5 – Combined bladder injury
◦ consisting of both intra and extraperitoneal rupture, represents approximately 5% of cases of major bladder injury.
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Imaging
• The bladder can be initially evaluated at IVU or the excretory phase of CTU.
• A normal appearance of the bladder on IVU or at the excretory phase of CTU does not exclude a bladder injury.
• Static or CT cystography with retrograde filling of the bladder with contrast would be required to exclude bladder injury. Cystography is reported to be accurate in the assess- ment of bladder injury in 85–100% of cases.
• In male patients, a retrograde urethrogram must be performed before placement of a Foley catheter if there is clinical concern for a urethral injury.
• Static cystography consists of
◦ a scout radiograph followed by the initial retrograde instillation of approximately 100 ml of 20–30% contrast material to assess for gross bladder extravasation.
◦ Subsequently, an additional 200–250 ml of contrast is infused to completely fill the bladder.
◦ A 14×17 inch radiograph of the entire abdomen will effectively demonstrate the pattern of extravasation.
◦ A post-drainage radiograph is obtained after emptying the bladder to demonstrate con- trast extravasation that may have been obscured by a distended bladder, an occurrence encountered in approximately 10% of cases of bladder rupture.
• CT cystography
◦ The bladder is filled retrograde with at least 350 ml of dilute (3–5%) contrast material.
◦ 10 mm contiguous axial sections are obtained through the pelvis.
• Cystography findings
◦ Bladder contusion
Normal cystogram.
◦ Interstitial bladder injury
A defect in the bladder wall representing an intramural hematoma is observed, how- ever contrast extravasation is notably absent (Fig. 7.7a).
◦ Intraperitoneal rupture
Contrast extravasation into the paracolic gutters and contrast outlining loops of small bowel is observed (Fig. 7.7b).
◦ Extraperitoneal rupture
Insimpleextraperitoneal rupture, extravasation is limited to the pelvic extraperitoneal space (Fig. 7.7c).
Incomplexextraperitoneal rupture, contrast extends into the anterior abdominal wall, penis, scrotum, perineum, or down the leg (Fig. 7.7d).
◦ Combined bladder injury
Features of both intra and extra peritoneal rupture are present.
◦ Penetrating injuries
May result in intraperitoneal, extraperitoneal, or combined bladder ruptures.