2014 Top Stories in Urology: AUA Urotrauma Guidelines

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:

  1. The surgical team must perform immediate surgery (or angioembolization in selected situations) in hemodynamically unstable patients with no or transient response to resuscitation.
  2. Follow-up imaging is necessary for high-grade renal injuries, although the particular lesions and how to follow them remains unknown.
  3. Ureteral injury should be explored and repaired immediately; if diagnosis is delayed, use a drain-and-wait approach.
  4. Intraperitoneal bladder rupture should always be repaired after blunt trauma.
  5. 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.
  6. 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.
  7. 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.
  8. 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.

Routine Urinalysis Not Helpful After Blunt Abdominal Trauma.

Routine urinalysis after blunt abdominal trauma won’t help find urogenital injury, Dutch researchers say.

“With the advancements made in CT scanning, there is now much greater accuracy in the detection (or ruling out) of injury to the urogenital system,” Dr. J. Carel Goslings from Academic Medical Center in Amsterdam told Reuters Health.

“In this study,” Dr. Goslings added, “we found the value of the routine performance of urinalysis in patients with a blunt trauma mechanism to be limited.”

The retrospective study involved 1815 patients. Most patients — 1031, or 57% — also had imaging studies, according to a paper online September 16th in Emergency Medicine Journal.

Among the patients who had imaging studies done, 795 (77%) had no hematuria, 220 (21%) had microscopic hematuria, and 16 (2%) had macroscopic hematuria.

Of the 220 patients with microscopic hematuria, eight had abnormal urogenital imaging studies, but only three of the eight had clinical consequences. Another eight patients with microscopic hematuria did have clinical consequences despite normal-looking imaging.

There were 332 patients who had urine collected but no imaging studies. In this group, 278 patients (84%) had no hematuria. In the 54 patients (16%) who did have microscopic hematuria, there were no clinical consequences, according to the authors.

Two hundred sixty-eight patients (15%) had urogenital imaging but no urinalysis. Only 10 had abnormal findings; four of the 10 had clinical consequences.

Ten percent of patients had neither urine collection nor imaging.

“The potential danger of performing urinalysis without imaging is to miss clinically relevant injuries (e.g., bleeding sites in the kidney parenchyma), which can only be shown by imaging,” the authors wrote. “Bypassing urinalysis and going straight for imaging…results in clinical consequences in 1.5% of the patients (4 out of 268). This is comparable to the percentage of clinical consequences in the patients who receive both urinalysis and imaging (2%; 22 out of 1031).”

They added, “The remaining 0.5% difference in clinical consequences consists of relatively minor consequences such as additional imaging and re-evaluation at the outpatient department, and this indicates little added value of the performance of urinalysis.”

Dr. Goslings told Reuters Health that the researchers “advise omitting this investigation as a routine part of the assessment of trauma patients, given that (good) imaging facilities are available in the hospital.”

But in specific circumstances, urinalysis might still be appropriate. Repeating by email some points from the paper, Dr. Goslings wrote, “In particular, patients with specific trauma mechanisms (e.g., fall from height, fall from horse or direct blow to the flank) or patients with a suspicion of pelvic (ring) injuries or thoracolumbar spinal cord injuries might benefit from urinalysis.”

“Future studies should focus on identifying the subgroups of patients in whom urinalysis is helpful,” Dr. Goslings added.