SILVIA OBENAUER 1 , KLAUS-DIETER PLOTHE 2 , ROLF H. RINGERT 2 & MARKUS HEUSER 2 Departments of 1 Diagnostic Radiology and 2 Urology, Georg-August-University, Go ttingen, Germany Abstract The kidney, bladder and male urethra are the organs typically injured by blunt and penetrating trauma to the urinary tract, whereas the ureter is only rarely injured. The staging of genitourinary tract trauma has recently gained tremendous significance due to improvements in ultrasound, CT and MRI, including contrast-enhanced magnetic resonance angiography, and has become a helpful tool for decision making with regard to conservative and surgical management. Furthermore, interventional radiology may be helpful to control hemorrhage from vessels in the pelvic region that may not be easily accessed by open surgery. Therefore, this pictorial essay gives examples of the radiological presentation of genitourinary trauma and describes technical details of the diagnostic imaging modalities used. Introduction The urogenital tract is involved in :/10% of all patients exposed to blunt and penetrating trauma [1,2]. In general, the kidney, bladder and male urethra show distinct trauma patterns, whereas the female urethra and ureter are infrequently injured. Decision making regarding conservative or operative management of urologic trauma depends primarily on the presence or absence of hemodynamic in- stability due to ongoing blood loss, and this may force the urologic specialist to proceed to the operating room without performing adequate ima- ging studies. However, in the majority of trauma patients, diagnostic imaging is mandatory for an exact staging of genitourinary trauma [1,2]. This pictorial essay gives examples of the radiological presentation of renal, vesical and urethral trauma and briefly describes the therapeutic consequences of various findings. All patients were investigated in the course of routine diagnostic work-up. Material and methods CT images were performed on an eight-slice multi- detector CT system (LightSpeed Ultra; GE, Mil- waukee, WI). Normally, a non-contrast scan was performed, together with a contrast scan with CT angiography and venous and excretion phases. MR angiography was done using a 1.5-T MR unit (Symphony; Siemens, Erlangen, Germany) as con- trast-enhanced MR angiography with 3D gradient echo sequences. Subtraction images were available [36]. Renal trauma Clinically, patients with renal trauma present with micro- or macrohematuria and flank pain. The severity of renal trauma is classified according to the American Association for the Surgery of Trauma Organ Injury Score [2,3] into five different grades. The assignment of an injury to a specific severity grade in this grading system depends on the presence of single or multiple parenchymal ruptures, the depth of parenchymal rupture, lesions of the renal pelvis with extravasation of urine and trauma to the major renal vessels. Grades IIII can be clearly established by means of appropriate studies, but there are areas of overlap between grades IV and V (e.g. vascular and parenchymal injury can be present in both) [2]. Contrast-enhanced CT in the renal excretion phase is the imaging technique of choice Correspondence: Silvia Obenauer, MD, Department of Diagnostic Radiology, Georg-August-University, Robert-Koch-Strasse 40, 37099 Go ttingen, Germany. Tel: /49 551 398965. Fax: /49 551 399606. E-mail: soben@med.uni-goettingen.de Scandinavian Journal of Urology and Nephrology, 2006; 40: 416422 (Received 1 December 2005; accepted 4 April 2006) ISSN 0036-5599 print/ISSN 1651-2065 online # 2006 Taylor & Francis DOI: 10.1080/00365590600796642 for the staging of renal ruptures and for the planning of renal reconstruction, whereas excretory urography and angiography are only used in special cases (Figures 13) [3]. For the detection of urine leaks, delayed CT imaging after application of contrast medium is essential. Urinomas may be confined, encapsulated fluid collections or may manifest as free fluid. However, most urinomas leak into a subcapsular location or into the perirenal space within Gerotas fascia. If extensive, a urine leak may cross the midline within the perirenal space anterior to the aorta and inferior vena cava and extend into the contralateral perirenal space. Indica- tions for renal exploration after trauma can be separated into absolute and relative. Absolute indications include evidence of persistent renal bleeding, expanding perirenal hematoma and pulsa- tile perirenal hematoma. Relative indications are urinary extravasation, non-viable tissue, delayed diagnosis of arterial injury, segmental arterial injury and incomplete staging [4]. The operative manage- ment of renal rupture includes delayed or immediate reconstruction of the renal pelvis and sutures of the parenchyma (Figure 4). In the case of vascular lesions, arterial reconstruction or bypassing may be necessary if the duration of warm ischemia does not exceed 8 h [47]. Bladder trauma Trauma to the urinary bladder includes contusions and ruptures. Any macrohematuria in association with pelvic or lower abdominal trauma may be evidence of bladder injury. Whereas bladder contu- sions do not require any treatment, a vesical rupture must be treated by means of either transurethral catheter drainage if urine is leaking into the extraperitoneal paravesical space or surgical closure if there is leakage of urine into the peritoneal space. Bladder ruptures are diagnosed by means of transurethral cystography. In trauma patients the Foley catheter should be clamped before CT imaging in order to reveal bladder trauma. If a bladder injury is not demonstrated on the initial CT scan and the pelvic injuries are serious enough to cause concern about a bladder injury, then a retrograde study must be performed with adequate bladder filling. CT cystography may reveal extra- or intraperitoneal rupture of the bladder (Figure 5) [8,9]. Ureteral trauma Ureteral injuries after a violent attack are rare and their diagnosis is often delayed. However, if ureteral injuries are found after blunt trauma, there is a high probability of associated visceral injuries (bowel, kidney, bladder). Thus, further diagnostic imaging (CT) is recommended [10]. Urethral trauma Traumatic urethral lesions are typically complete or incomplete ruptures and occur mainly in males. They are classified into infradiaphragmal and supra- diaphragmal lesions according to the localization of the defect in relation to the pelvic floor. Whereas supradiaphragmal lesions are typically associated with an indirect blunt trauma to the lower abdomen, infradiaphragmal lesions are often seen after a straddle trauma to the perineal region. Bladder lesions are combined with urethral lesions in up to Figure 1. (a) CT scan of a patient after a trauma to the left ank. A small subcapsular uid collection (black arrow) can be seen dorsally in the left kidney as a sign of renal contusion (grade 1). (b) CT scan of a motorcyclist after a collision with a car showing a right subcutaneous and perirenal hematoma (black arrow), rib and vertebral body fractures, together with a rupture of the renal parenchyma that did not extend into the collecting system (renal injury grade 2/3) (white arrow). Conservative therapy was chosen. Imaging of genitourinary trauma 417 Figure 3. (a) Typical grade 5 renal rupture due to blunt trauma with a big retroperitoneal hematoma in the native series without intravenous contrast medium (black arrow). (b) After injection of contrast medium, a completely ruptured right kidney with multiple lacerations can be seen (black arrow). (c, d) In an excretion series, highly concentrated contrast medium can be seen extravasating into the retroperitoneal space, a typical sign of disruption of the renal pelvis (black arrows ). Delayed surgical reconstruction was done. Figure 2. (a, b) CT scans of a young patient after blunt trauma. The radiological ndings are typical of intimal disruption of the left renal artery with consequent thrombosis because the kidney does not take up contrast medium through the renal artery but only through small capsular vessels (black arrow). Furthermore, a major medial hematoma is completely absent (white arrow), indicating that there is not complete disruption of the renal artery or vein. (c, d) MRI scans of the kidney. (c) A T1-weighted image in the coronal view after contrast medium injection reveals perfusion of the right kidney and no enhancement of the left kidney. (d) MR angiography after subtraction technique in the maximum intensity projection conrmed the presence of renal artery intima disruption (white arrow). No revascularization was possible due to the long period of ischemia of the kidney. 418 S. Obenauer et al. 20% of cases. Clinically, urethral disruption is associated with the triad of blood at the urethral meatus, inability to urinate and a palpably full bladder. Retrograde injection of contrast medium into the urethra is safe and has high sensitivity for making the diagnosis of urethral rupture. Surgical therapy consists of realignment of the ruptured urethral segments and catheter drainage (Figure 6) [1,11]. Vascular lesions to the urogenital tract In a few cases of polytraumatized patients with pelvic fractures, significant bleeding is seen resulting from an injury to the internal iliac vessels and their branches, e.g. the scrotal artery. In these cases, surgical therapy may be difficult. Embolization, e.g. with coils or with polyvinyl alcohol particles in the feeding vessels, is a suitable alternative to open surgery. According to Ben-Menachem et al. [12], reliable occlusion of bleeding vessels may be achieved in :/11% of all patients with pelvic fractures. However, early stabilization of the frac- ture remains the most effective way of decreasing blood loss in these cases (Figure 7) [13]. CT and magnetic resonance (MR) angiography are gaining increasing importance for studying these lesions. However, the disadvantage of these non-invasive techniques is the inability to stop bleeding with interventional vaso-occlusive measures. In particu- lar, intimal dissections and complete renal artery disruptions may be diagnosed with these novel techniques if the patient is stable enough to permit diagnostic imaging. Lesions to the penis vessels, e.g. after traumatic amputation, can be surgically managed by micro- scopic anastomosis of the dorsal artery and repair of the profound dorsal vein after closure of the urethra and suture of the tunica albuginea, whereas the cavernosal arteries cannot be reanastomosed. Figure 4. (ac) Trauma of the kidney with renal rupture grade 5. CT scans show multiple lacerations of the left kidney with a completely shattered kidney, whereas the pieces of the kidney are well vascularized (black arrows ). (df) CT scans taken 8 months after surgical reconstruction of the kidney reveal a few perfusion inhomogeneities due to scars, while the whole kidney is well reconstructed (black arrows ). Imaging of genitourinary trauma 419 Technical aspects of imaging The role of imaging has increased tremendously in recent years, with important improvements in color Doppler ultrasound and ultrasound contrast agents. There have also been important improvements in CT technology, such as multi-detector spiral CT, which enables both CT angiography and parenchy- mal imaging of urinary trauma patients. Imaging of the kidney and renal arteries can be done in a few seconds. Acquisition of multiple thin overlapping slices provides excellent 2D and 3D visualization of the urinary tract. CT is the study of choice for the diagnosis of renal urine leaks and urinomas. CT protocols in patients with a suspected urine leak involve scanning the abdomen and pelvis prior to and following the i.v. administration of 100150 ml of contrast material. Delayed-phase images obtained 520 min after injection of contrast material are the key to demonstrating a urine leak, because iodinated urine increases the attenuation of the urinoma over time. There have also been important improvements in MRI, such as contrast-enhanced MR angiogra- phy, as well as MR angiography without contrast administration using the true FISP (Fast Imaging with Steady state Precession) technique. These techniques allow the non-invasive visualization of vessels in traumatized patients. However, MRI is not the method of choice for traumatized emergency patients. Radiotracer excreted outside the genitour- inary tract at either bone or renal scintigraphy may Figure 5. (a) Normal cystogram. (b) Image from a patient after a motorcycle accident showing the typical pattern of an extraperitoneal bladder rupture with leakage of contrast medium into the perivesical extraperitoneal space (black arrow). (c) Cystogram of a patient with an intraperitoneal bladder rupture (black arrow). (d) CT scan of an extraperitoneal rupture of the bladder with contrast medium in the extra- or retroperitoneal space (black arrow). Figure 6. (a) Normal retrograde urethrogram. (b) Typical image of a supradiaphragmal urethral rupture (black arrow). 420 S. Obenauer et al. also allow a diagnosis of urine leak. I.v. pyelography is relatively insensitive for the diagnosis of renal injuries and urine leaks and may demonstrate normal findings in /30% of cases with significant renal injury. Furthermore, i.v. pyelography cannot be used in emergency patients. Cystography was formerly the diagnostic test of choice for evaluating the presence of a urinary bladder injury. However, CT cystography is now performed at many institu- tions. This method aids the detection of coexisting injuries to the pelvis and is more sensitive for determining the true extent of bladder injury. Conclusions Various factors have to be considered when deciding between operative or conservative management of urogenital trauma. In an unstable patient with hypovolemic shock, even after appropriate resuscita- tion measures, it will not be possible to perform time-consuming diagnostic imaging, and the trauma site will be surgically explored. In all other (stable) patients, who represent the majority of cases with relevant urological lesions, further diagnostic ima- ging is extremely helpful before deciding how to proceed. Renal, bladder and urethral injuries may be exactly defined, and plastic reconstruction is facili- tated. Moreover, hemodynamically relevant bleeding may be stopped in areas, such as the pelvis, that are difficult to access surgically. Therefore, the clinical urologist should be aware of the available diagnostic and interventional radiological repertoire. References [1] Mitchell JP. Trauma to the urinary tract. Br Med J 1971;/2:/ 56773. 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Traumatic posterior urethral injury and early primary endoscopic realignment: evaluation of long-term follow-up. Urology 1999;/53:/120510. [12] Ben-Menachem Y, Coldwell DM, Young JWR, Burgess AR. Hemorrhage associated with pelvic fractures: causes, diag- nosis and emergent management. AJR Am J Roentgenol 1991;/157:/100514. [13] Wells J. Internal iliac artery embolization in the management of pelvic bleeding. Clin Radiol 1996;/51:/8257. 422 S. Obenauer et al.