Trauma and reconstructive urology: grading, drainage and delayed repair
What the exam tests
Imaging and decision-making in blunt and penetrating trauma to the kidney, bladder and urethra, plus reconstructive options for stricture disease and ureteric injury.
Core rules
- Renal trauma is graded I to V on CT with delayed phases. Haemodynamically stable patients, including most grade IV injuries, are managed conservatively; unstable patients, or those with a shattered kidney or pedicle avulsion, need exploration.
- Bladder rupture: extraperitoneal rupture usually follows pelvic fracture and is managed with catheter drainage; intraperitoneal rupture (dome blowout) needs surgical repair.
- Suspected urethral injury, with pelvic fracture, blood at the meatus, inability to void or perineal bruising, means no urethral catheter. Perform a retrograde urethrogram and place a suprapubic catheter.
- Testicular rupture and large haematoceles need exploration.
- Urethral stricture: short bulbar strictures may suit anastomotic urethroplasty; long or recurrent strictures need augmentation with buccal mucosa. Repeated dilatation is not curative.
- Iatrogenic ureteric injury during pelvic surgery should be recognised and stented or reimplanted at the time.
Worked example
A motorcyclist has a pelvic fracture, blood at the meatus and cannot void. Reasoning: the posterior urethra is at risk. Passing a urethral catheter could convert a partial into a complete disruption, so perform a retrograde urethrogram, divert urine with a suprapubic catheter, and plan delayed urethroplasty once the fracture and soft tissues have settled.
Traps
Urethral catheterisation in suspected urethral injury; missing intraperitoneal bladder rupture on CT; assuming all grade IV renal injuries need nephrectomy; treating a recurrent stricture with lifelong dilatation.