APPENDIX A: UROLOGICAL DIAGNOSIS AND TREATMENTS

#### Hematuria

Treatment:

- Place a Foley catheter during trauma assessment unless contraindicated, such as blood at the urethral meatus or other evidence of urethral injury (pelvic fracture).
- Perform a retrograde urethrogram (RUG) before attempted catheterization when there is a concern for a urethral injury.
- RUG – Obtain an oblique plain film of the pelvis with the patient's bottom leg flexed at the knee and hip with the top leg straight. Severely injured patients or those with suspected spine fractures can be left supine. Alternatively, C-arm or fluoroscopy can be used. A 12 Fr Foley catheter or catheter-tipped syringe is inserted into the fossa navicularis; the penis is placed on traction, and 20 mL of undiluted water-soluble contrast is injected under gentle pressure. Images are obtained. The study is considered normal only if contrast enters the bladder without extravasation.
- For an anterior urethral injury, plan on repair in the operating room (OR). For a posterior urethral injury, a suprapubic catheter can be placed in the OR or percutaneously in the emergency department (ED) for patients who do not need surgery, and an appropriate kit is available. For partial urethral disruption by RUG, a single attempt with a well-lubricated catheter may be attempted by an experienced team member in the ED.
- If the catheter passes and gross hematuria is noted, proceed with GU diagnostic evaluation for bladder injury or a renal/ureteral source. C. scan with delayed images and CT cystogram are appropriate imaging studies (see technique description following).

#### Renal Injury

Treatment:

- Clinicians should perform diagnostic imaging with intravenous (IV) contrast-enhanced computed tomography (CT) with delayed imaging in stable blunt trauma patients with gross hematuria or microscopic hematuria and systolic blood pressure < 90mmHG or in any stable trauma patients with the mechanism of injury or physical exam findings concerning for renal injury (e.g., rapid deceleration, significant blow to flank, rib fracture, significant flank ecchymosis, penetrating injury of abdomen, flank, or lower chest).
- Renal Injury Grading
- Grade 1: Sub-capsular hematoma
- Grade 2: Small parenchymal laceration (<1cm in depth)
- Grade 3: Deeper parenchymal laceration without entry into the collecting system
- Grade 4: Laceration into collecting system with extravasation; vascular injury with contained hemorrhage
- Grade 5: Shattered kidney or renal pedicle avulsion
- Hemodynamically stable patients can be managed without surgical exploration in most cases.
- Hemodynamically unstable patients with no or transient response to resuscitation should have an immediate intervention.
- Vascular repair is indicated for salvageable kidneys with renal artery or vein injury.
- Ureteral stenting may be needed for enlarging urinoma or persistent urinary extravasation with fever, pain, ileus, fistula, or infection.

#### Renal Exploration During Abdominal Operation

Treatment:

- Stable perirenal hematomas found during exploration should not be routinely opened.
- Penetrating injuries to retroperitoneal zone 2 should be explored.
- Renal exploration should be performed at the time of laparotomy for persistent bleeding, expanding hematoma, or a central hematoma suggesting a renal hilum injury.

#### Nephrectomy

Treatment:

- Total nephrectomy is immediately indicated in extensive renal injuries when the patient's life is threatened by attempted renal repair.
- A common surgical approach is a lateral to medial mobilization of the kidney to expose the renal pedicle after incision of the peritoneal attachments of the colon to the lateral wall. While there is insufficient data to recommend initial vascular control of the renal pedicle through a mesentery window before exploration, this remains an acceptable principle for isolated renal surgery.
- Damage control by packing the wound to control bleeding and attempting to correct metabolic and coagulation abnormalities, with a plan to return for corrective surgery within 24 hours is an option.

#### Renal Repair and Partial Nephrectomy Principles

Treatment:

- Non-surgical management can result in renal preservation even with high-grade injuries. Renal repair is appropriate after gaining hemorrhage control and hemodynamic stability for potentially salvageable kidneys identified during exploration.
- Technique: Complete renal exposure, debridement of non-viable tissue, hemostasis by individual suture ligation of bleeding vessels, watertight closure (absorbable suture), drainage of the collecting system, and coverage/approximation of the parenchymal defect.
- Perform partial nephrectomy if reconstruction is not possible: the collecting system must be closed, and the parenchyma covered with fat or omentum. Consider the use of hemostatic agents and tissue sealants if available.
- Place ureteral stent for persistent urinary extravasation.

#### Bladder Injuries

Treatment:

- Perform retrograde cystography in patients with gross hematuria and a mechanism concerning for bladder injury or a finding on exam or imaging concerning for bladder rupture or pelvic ring fracture.
- Retrograde cystography can be done by CT or plain film. For CT cystogram, use diluted Conray to reduce scatter artifact from the contrast. A minimum of 300 mL is needed for an adequate study. Another imaging with the bladder emptied of contrast should also be obtained. Plain film images should include a scout film and an AP image with or without oblique views, both with the bladder full and again after it is drained.
- In most cases, extraperitoneal extravasation of contrast can be managed with Foley catheterization alone. Open repair is indicated for complicated ruptures, including pelvic fractures with exposed bone spicules in the bladder and concurrent rectal or vaginal lacerations that may lead to fistula formation. Patients undergoing exploration for other appropriately stable indications and those with significant bladder neck involvement should be considered for closure. A transvesical approach can reduce the disruption of the pelvic hematoma.
- Intraperitoneal rupture requires open repair, two-layer closure with absorbable suture, and perivesical drain placement. A large caliber urethral catheter without a suprapubic catheter is usually sufficient for bladder drainage. Patients with complex lower extremity, pelvic, or perineal injuries and those requiring prolonged immobilization may also benefit from suprapubic catheter drainage.
- Follow up cystography should be performed before catheter removal.

#### Ureteral Injuries

Treatment:

- Identification of ureteral injury requires a high index of suspicion. Therefore, it should be evaluated with IV contrast-enhanced CT with delayed imaging or direct inspection during laparotomy if preoperative imaging is not available.
- Ureteral contusions can be managed by stenting or judicious excision of the injured area with primary anastomosis, depending on its severity. Simple ureteral lacerations should be closed primarily over a stent.
- Complete transections of the ureter proximal to the iliac vessels can be repaired using a tension-free, end-to-end, spatulated anastomosis over a ureteral stent. Transections distal to the vessels should be managed with a ureteral reimplantation over a stent. A psoas hitch or Boari flap may be necessary in some cases.
- In cases of inadequate ureteral length to re-anastomose or hemodynamic instability of the patient intraoperatively, a pediatric feeding tube or open-ended ureteral catheter may be placed in the proximal ureter, brought out through the skin, and placed to closed drainage. Reconstruction of the ureter can then be performed at a future date.
- A ureteropelvic junction avulsion injury should undergo re-anastomosis of the ureter to the renal pelvis over a stent.
- A drain should be considered after ureteral repair.

#### External Genitalia Injuries

Treatment:

- The primary goals in managing genital injuries are hemorrhage control and tissue preservation.
- Hemorrhage can occur from small arteries on the dorsal penile shaft or the spermatic cord. These vessels can be managed with precise cautery.
- Large-volume, low-pressure irrigation with normal saline should be performed with each surgical intervention. Delayed wound closure is appropriate for significant injuries with considerable tissue damage. Negative pressure wound dressings are well tolerated but often require creative placement techniques when applied to the genitalia. A non-adherent silicone or hydrophilic white foam dressing can be used to cover exposed testicles or freshly repaired corporal tissue when using a negative pressure dressing.
- Penile injury may include the corpus spongiosum or corpora cavernosa and can result in continued hemorrhage. These can be repaired by approximating the tunical margins with absorbable sutures in a hemostatic fashion following irrigation and debridement of necrotic or devitalized tissue.
- The glans is well vascularized and can generally be closed with interrupted absorbable suture.
- Scrotal injuries are managed similarly to other soft tissue wounds. Small penetrating injuries or blast mechanisms can result in significant testicular damage. There should be a low threshold for BILATERAL surgical exploration in these cases. The scrotum should undergo irrigation and debridement with primary or delayed closure. Widely spaced absorbable suture and a Penrose drain can be used in place of a negative pressure dressing when delayed closure is required.
- Testicle injuries can be diagnosed with a physical exam or scrotal ultrasound. CT or sonography may also show evidence of foreign bodies or air in the scrotum or abnormality of one or both testes. Equivocal cases should be explored. Necrotic testicular tissue should be debrided, and the capsule closed with an absorbable suture. A tunical vaginalis flap can be used when the tunica albuginea is deficient for closure.

#### Urethral Injuries

Treatment:

- Diagnosis: A RUG should be performed for suspected urethral injury. For partial urethral tears, a single attempt at urethral catheterization with a well-lubricated catheter may be attempted by an experienced provider.
- If unable to perform a RUG and urethral injury is suspected, place a suprapubic catheter.
- Anterior urethral injuries: Primary repair of uncomplicated penetrating injury to the anterior urethra may be performed using fine absorbable sutures with careful mucosal-to-mucosal apposition over a urethral catheter. Immediate repair should not be performed in the setting of extensive tissue damage, urethral loss, patient instability, or surgeon inexperience. Bleeding from the corpus spongiosum can be controlled with site-specific fine absorbable sutures. Bladder drainage should be established by urethral catheterization or suprapubic drainage.
- Posterior urethral injuries: These injuries are typically associated with pelvic fractures or deep penetrating trauma. Suprapubic urinary drainage with delayed reconstruction is the preferred treatment for the majority of cases.