Evaluation of urinary extravasation after non-operative management of traumatic renal injury: a multi-center retrospective study

Purpose Urinary extravasation is one of the major complications after non-operative management of traumatic renal injury and may lead to urinary tract infection and sepsis. The purpose of this study was to evaluate these factors in patients with traumatic renal injury. Methods This was a multi-center, retrospective, observational study performed at three tertiary referral hospitals in Osaka prefecture. We included patients with traumatic renal injury transported to the centers between January 2008 and December 2018. We excluded patients who either died or underwent nephrectomy within 24 h after admission. We investigated the occurrence of urinary extravasation and the related factors after traumatic renal injury using multivariable logistic regression analysis. Results In total, 146 patients were eligible for analysis. Their median age was 44 years and 68.5% were male. Their median Injury Severity Score was 17. Renal injuries were graded as American Association for Surgery of Trauma (AAST) grade I in 33 (22.6%), II in 27 (18.5%), III in 38 (26.0%), IV in 28 (19.2%), and V in 20 (13.7%) patients. Urinary extravasation was diagnosed in 26 patients (17.8%) and was statistically significantly associated with AAST grades IV–V (adjusted odds ratio, 33.8 [95% confidence interval 7.12–160], p < 0.001). Conclusion We observed urinary extravasation in 17.8% of patients with non-operative management of traumatic renal injury and the diagnosed was made in mostly within 7 days after admission. In this study, the patients with AAST grade IV–V injury were associated with having urinary extravasation.

Intraperitoneal Bladder Injury – A Conservative Approach

Iatrogenic bladder injuries with Intra-peritoneal extravasations are standardly managed surgically. However, we are presenting a case of iatrogenic intra-peritoneal bladder injury which developed after an emergency caesarean section that was managed successfully by conservative therapy. The trial of conservative approach may prove beneficial to minimize the chances of any invasive interventions in such cases. Bladder injuries are of two types namely intra-peritoneal and extra-peritoneal. Of which, extra-peritoneal is most common type.1 Bladder laceration happens during separation of bladder from uterine cervix during caesarean sections and abdominal hysterectomies.2 Usually bladder injuries are identified intra-operatively and managed on table. If diagnosis is made post-operatively, then management becomes challenging due to non-specific clinical features, exposure to radiation, sepsis due to urinary extravasation and prolonged hospital stay, psychological stress to both patient and surgeon. The clinical features suspicious of bladder injury are abdomen distension, urinary ascites, blood-stained urine, abdominal pain, paralytic ileus, fever and deranged renal parameters.3 Extra-peritoneal and intra-peritoneal bladder ruptures are treated differently. According to American Urological Association (AUA) guidelines, Intraperitoneal bladder injury needs surgical repair. There are limited case reports in literature about conservative management of small intra-peritoneal bladder lacerations. This is a case report of one such intra-peritoneal bladder injury treated with non-operative approach.

Evaluation of Urinary Extravasation After Non-Operative Management of Traumatic Renal Injury: A Multi-Center Retrospective Study

Background: Urinary extravasation is one of the major complications after non-operative management of traumatic renal injury and may lead to urinary tract infection and sepsis. However, there is a paucity of research on timing of the occurrence or the risk factors of urinary extravasation among patients with traumatic renal injury. The purpose of this study was to evaluate these factors in patients with traumatic renal injury.Methods: This was a multi-center, retrospective, observational study performed at three tertiary referral hospitals in Osaka prefecture. We included patients with traumatic renal injury transported to the centers between January 2008 and December 2018. We excluded patients who either died or underwent nephrectomy within 24 hours after admission. We investigated the occurrence of urinary extravasation and the related factors after traumatic renal injury using multivariable logistic regression analysis.Results: In total, 146 patients were eligible for analysis. Their median age was 44 years and 68.5% were male. Their median Injury Severity Score was 17. Renal injuries were graded as American Association for Surgery of Trauma (AAST) grade I in 33 (22.6%), II in 27 (18.5%), III in 38 (26.0%), IV in 28 (19.2%), and V in 20 (13.7%) patients. Urinary extravasation was diagnosed in 26 patients (17.8%) and was statistically significantly associated with AAST grades IV-V (adjusted odds ratio, 33.8 [95% confidence interval, 7.12–160], p<0.001).Conclusion: We observed urinary extravasation in 17.8% of patients with non-operative management of traumatic renal injury and the diagnosed was made in mostly within 7 days after admission. In this study, the patients with AAST grade IV-V injury were associated with having urinary extravasation.

Management of high-grade renal traumas with collecting system injuries

Introduction: Approximately 50% of all high-grade renal traumas (HGRT, American Association for the Surgery of Trauma [AAST] grade 4/5) have associated collecting system injuries. Although most of these collecting system injuries will heal spontaneously, approximately 20–30% of these injuries are managed with ureteric stents. The objective of the study was to review the management of HGRT with collecting system injuries in a level 1 trauma center. Methods: This was a single-center, retrospective cohort study of trauma patients with HGRT and collecting system injuries from 1998–2019. Results: We identified 147 patients with HGRT. Of the 105 patients who had trauma computed tomography (CT) imaging within 24 hours, 46 were found to have collecting system injuries. Seven of these patients underwent intervention based on initial CT findings; the remaining 39 patients with urinary extravasation were conservatively managed. Of the 37 patients who underwent reimaging, 22 (59%) demonstrated a stable or resolving collection and 15 (41%) demonstrated continued urinary extravasation. Resolution of extravasation on subsequent imaging was observed in 10 of those patients, while five patients (14%) required intervention (four stents, one percutaneous drain) for symptoms/signs of urinary extravasation. Conclusions: In this study, most patients with HGRT and collecting system injuries did not require intervention unless the patient became symptomatic. The majority of collecting system injuries resolved with no intervention. This study underscores the need for future prospective trials to investigate the necessity of intervening in HGRT collecting system injuries and, secondarily, the need for routine reimaging in these asymptomatic patients.

Triamcinolone acetonide injections for the treatment of recalcitrant post-radical prostatectomy vesicourethral anastomotic stenosis: A retrospective look at efficacy and safety

Introduction: We aimed to evaluate the success of bladder neck injections of triamcinolone at the time of transurethral bladder neck incision (BNI) for prevention of recurrent vesicourethral anastomotic stenosis (VUAS) following prostate cancer treatment. Methods: This is a retrospective cohort study examining patients with recurrent VUAS post-RP ± radiation treated with triamcinolone injections at the time of BNI. VUAS was diagnosed by symptoms followed by cystoscopy or urethrography. The outpatient procedures were done under general anesthesia. Cold knife incisions were made at the three, nine, and 12 o’clock BN positions, followed by triamcinolone injections (4 mg/mL) into the three and nine o’clock incision sites. Treatment outcomes were determined with cystoscopy. Results: Eighteen men underwent 25 procedures over a four-year period. Median age at diagnosis of VUAS was 65 (interquartile range [IQR] 61–68); median time to VUAS from RP was eight months (IQR 5–12). Fourteen patients (78%) had radiation treatment. The cohort had 128 unsuccessful VUAS treatments, with a median of five failed treatments per patient (IQR 3–10). Failed treatments included BN dilation, BNI, BN injection of mitomycin C, and urethral stent placement. Success rate after a mean of 16.3 months (standard deviation [SD] 8.1) from the time of triamcinolone injection was 83% (15/18). Six patients went on to have successful incontinence surgery. Five patients (28%) had treatment complications (bleeding, urinary tract infection, pain, and urinary extravasation). The three non-responders are stable and awaiting re-treatment with triamcinolone injection. Conclusions: Triamcinolone bladder neck injections for post-RP VUAS are a useful and safe treatment for recurrent stenosis.