Role of imaging in evaluation of genitourinary i trauma Spectrum of GU injuries Relevance of imaging findings in determining management Focus on MDCT

Genitourinary Tract Injuries 6 th Nordic Course Scott D. Steenburg, MD Assistant Professor University of Maryland Department of Radiology Division of Trauma and Emergency Radiology R Adams Cowley Shock Trauma Center Objectives Role of imaging in evaluation of genitourinary i trauma Spectrum of GU injuries Relevance of imaging findings in determining management Focus on MDCT

Genitourinary Tract Adrenal glands Kidneys Ureters Bladder Urethra Genitourinary Tract Trauma 10% of all blunt abdominal trauma Trend towards conservative management Imaging directs management and further investigation

Adrenal Glands Incidence up to 4% of blunt trauma Unilateral, R>>L>bilateral Rarely isolated Adjacent injuries common Esp liver Unilateral adrenal injuries of little clinical significance Bilateral injuries rarely cause adrenal insufficiency Adrenal Glands CT imaging findings: Expansile, round or oval hyperattenuating hematoma Irregularity or obliteration by hemorrhage, Periadrenal fat stranding Enlargement due to edema or contusion

Adrenal Hematoma Adrenal Hemorrhage / Bare Area Contusion

Adrenal injury with active hemorrhage Renal Trauma 3 10% of blunt trauma patients Blunt trauma 80 90% Parenchymal Collecting system Vascular 95 98% of renal injuries managed conservatively

Renal Trauma Hematuria? Hematuria often absent Absent b in 10 25% of renal parenchymal injuries Absent in 25 50% of patients with ureteropelvic juntion injuries Ureteral tear, vascular pedicle injury, or ureteropelvic junction avulsion Kawashima A, Sandler CM, Corl FM, et al. Imaging of renal trauma: a comprehensive review. Radiographics 2001;21(3):557 74. Renal Trauma Hematuria? Nocorrelation betweendegreeof hematuria and extent of renal injury Kawashima A, Sandler CM, Corl FM, et al. Imaging of renal trauma: a comprehensive review. Radiographics 2001;21(3):557 74

Renal Trauma: Imaging Protocols MDCT primary imaging modality Anatomy and function Multi phase acquisition Arterial phase Parenchymal phase Delayed phase Renal Trauma

Grade I injuries Renal Trauma 75 85% of all renal injuries Contusions Non expanding subcapsular hematomas Renal Contusion / Laceration

Grade II injuries Renal Trauma Non expanding perinephric hematomas confined to the retroperitoneum Superficial cortical lacerations <1 cm in depth Grade III injuries Lacerations deeper than 1 cm Extendinto the medulla. Grade II and III lacerations spare the collecting system Subcapsular Hematomas Grade II Grade III

Grade IV injuries Renal Trauma Lacerations extending through h cortex, medulla and into the collecting system Injuries involving the main renal artery or vein with contained hemorrhage Segmentalinfarctions without associated lacerations Renal infarction Renal Trauma Stretching t of the renal artery produces an intimal tear or dissection CT findings: Segmental = peripheral, well defined, wedge shaped, non enhancing

Kawashima A, et al. Imaging of Renal Trauma: A Comprehensive Review. RadioGraphics 2001; 21:557 574 Renal infarction Renal Trauma Most segmental tlrenal infarcts heal spontaneously to form scars Infarcts >50% may need surgical debridement

Segmental Renal Infarct Segmental Renal Infarct

Multi-focal Segmental Renal Infarcts Grade V injuries Renal 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 devascularization i of the kidney

Right renal artery avulsion Right Infarct, Left Contusion

Right renal artery injury, renal infarct Shattered Kidney Multiple fragments Renal Trauma 1 or more devitalized areas regions Excreted contrast leak Injuries to the collecting system Severe hemorrhage Active arterial bleeding

Shattered Kidney Grade V Renal Injury with active bleeding

Renal vein pseudoaneurysm with active bleeding Left vein injury with active bleeding

Ureter Injuries Ureteropelvic junction Ureter Ureteropelvic junction Ureter Injuries 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% 50%

Ureter Injuries Delayed phase essential! >5min Leak on arterial and parenchymal phases often absent Ureter Injuries Partial laceration vs transection Partial laceration = leak of excreted contrast with opacified distal ureter Transection = leak of excreted contrast with unopacified distal ureter

Ureter Injuries Partial laceration vs transection Partial laceration: Treated conservatively or with stent placement Complete transection: Usually requires surgical repair Ureter Injuries Urinary extravasation alone is not an indication for surgery Can spontaneously resolve Up to 87% of patients Follow up imaging i recommended dd Knudson MM and Maull KI. Nonoperative management of solid organ injuries: past, present and future. Surg Clin North Am 1999; 79:1357 1367.

Uretero Pelvic Junction Laceration

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