Practicing urologists have always played an integral role in the evaluation and treatment of acute genitourinary organ injury. Well-established criteria for imaging of blunt trauma, originally pioneered by McAninch and colleagues, have been incorporated in most trauma center protocols. Although trauma surgeons may manage life-threatening renal hemorrhage with nephrectomy, urologist input remains critical when deciding appropriate intervention for all other urinary tract and genital injuries.
The field of genitourinary trauma and reconstruction received a major push toward dissemination of evidence-based best practices with the introduction of the AUA Guideline on Urotrauma.1 Guidelines drive education, policy, and changes in practice patterns that may be adopted worldwide. In addition, gaps in knowledge identified by the evidence review define opportunities for future research.
Urologists can expect two diverging outcomes of the introduction of guidelines. Trauma systems will look to the guidelines to ensure adherence with evidence-based recommendations. This will likely create greater demand for urological consultation and involvement during and after hospitalization. Conversely, if urologists are not willing to provide prompt engagement and collaboration with trauma teams, it is possible that other practitioners will take over decision-making and care of patients with genitourinary injuries.
Key takeaways from the AUA Urotrauma Guidelines include the following:
- The surgical team must perform immediate surgery (or angioembolization in selected situations) in hemodynamically unstable patients with no or transient response to resuscitation.
- Follow-up imaging is necessary for high-grade renal injuries, although the particular lesions and how to follow them remains unknown.
- Ureteral injury should be explored and repaired immediately; if diagnosis is delayed, use a drain-and-wait approach.
- Intraperitoneal bladder rupture should always be repaired after blunt trauma.
- Extraperitoneal bladder rupture can be classified into complicated and uncomplicated. Complicated injuries require exploration and repair, whereas uncomplicated injuries can be managed with catheter drainage.
- Suprapubic tubes may be used in the face of orthopedic hardware as determined by expert opinion; it must be acknowledged that there is little evidence to support the guideline recommendation.
- Primary urethral realignment is an option for pelvic fracture urethral injury. Suprapubic cystostomy is almost always the best initial choice for urinary drainage in the acute setting of a pelvic fracture urethral injury. Primary realignment will reduce stricture rates, but prolonged efforts at realignment should be avoided.
- Genital injuries require early exploration using correct approaches at the local hospital level based on the mechanism and severity of injury. An exception to this is penile replantation, which should be referred to centers of excellence for microvascular repair.