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xxvi
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Abbreviations
PCNL Percutaneous nephrolithotomy
PF Penile fracture
PFUDD Pelvic fracture urethral distraction defects
PFUI Pelvic fracture urethral injury
PSA Pseudoaneurysm
PTFE Polytetrauoroethylene
PUV Posterior urethral valves
RAFF Radial artery free ap phalloplasty
RFFF Radial forearm free ap
RGU/RGP Retrograde urography/pyelography
RIRS Retrograde intrarenal surgery
RTA Road trafc accidents
RTS Revised trauma score
RUG Retrograde urethrography
SIU Societé Internationale d’Urologie
SIU-ICUD Société Internationale d’Urologie—International Consultation on
Urological Diseases
SNVB Subcutaneous nephron-vesical bypass
SPC Suprapubic catheter
SSCs Spermatogonial stem cells
TAE Transcatheter angiographic embolization
TARN Trauma Audit and Research Network
TDT Traumatic dislocation of the testis
TESE Testicular sperm extraction
TURBT Transuretheral resection of bladder tumour
TURP Transuretheral resection of prostate
UGT Urogenital trauma
US Ultrasound (ultrasonography)
USI Urological Society of India
UTI Urinary tract infection
WHO World Health Organization
WSES World Society of Emergency Surgery
WSES-AAST World Society of Emergency Surgery and the American Association
for the Surgery of Trauma
ZIRPI Zipper-related penis injuries
Part I
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Renal Trauma
Kidneys are double-edged swords. They are indispensable for your life by
removing waste and excess water. But they are also blood bombs that might
explode when hit and jeopardize your life.
Introduction toRenal Trauma
Although ancient humans did not know the exact function of the kidneys, they suspected very early their vital importance in the body. Thus, when mummifying
important personalities, old Egyptians used to remove all organs, except the heart
and the kidneys [1]. The biblical conception of kidneys also placed them as the seat
of conscience and impetus for ethical yearning [2].
Nowadays, thanks to tremendous progress in the anatomy, anatomical pathology,
physiology, and physiopathology of the kidney, the spiritual part of these old
thoughts has completely faded while the vital role of this organ has been conrmed.
However, this role doesn’t provide any shield to the kidney against internal or external insults, since this organ is frequently the target of various infections, malignancies, congenital abnormalities, and other pathologies that interfere with its noble
function: stones, diabetes, hypertension, atherosclerosis, systemic lupus erythematosus, drugs, etc. As if that weren’t enough, the kidneys are also the most vulnerable
urogenital organs in trauma, being involved in 41% of cases [3].
In the majority of cases, the kidneys are subjected to blunt trauma as a result of
motor vehicle accidents (MVA) [4, 5]. Less frequently, they are injured in penetrating trauma by projectiles (bullets), i.e., gunshot wounds (GSW) or by stubbing
instruments (knives). A minority of cases are iatrogenic resulting from minimally
invasive treatment such as extracorporeal shock wave lithotripsy (ESWL), endourological procedures, percutaneous nephrolithotomies (PCNL), percutaneous kidney
biopsy, and angiographic procedures. More rarely the kidneys can suffer deceleration injuries during falls from height.
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In almost all cases, the specic cause of the trauma is obvious, and the patient is
present with loin pain associated or not with hematuria. Depending on the severity
of the injury, he/she might be stable or in a state of cardiovascular shock caused by
massive bleeding and hypovolemia. Fever can be observed in late presentations
associated with a hematoma or urinoma.
Nowadays, the cornerstone of the diagnosis and grading of renal trauma is
contrast- enhanced computed tomography (CECT). The current trend is toward
conservative treatment, and interventions are seldom required being triggered
either by the patient’s cardiovascular instability or when his condition deteriorates,
and minimally invasive procedures are the preferred approach here, while open surgical interventions are exceptionally performed [6–8].
Renal Trauma
References
1. Greydanus DE, Kadochi M.Reections on the medical history of the kidney:
from Alcmaeon of Croton to Richard Bright—standing on the shoulders of
giants. J Integr Nephrol Androl. 2016;3:101–8.
2. Kopple JD.The biblical view of the kidney. Am J Nephrol. 1994;14(4–6):279–81.
https://doi.org/10.1159/000168735.
3. Terrier J-E, Paparel P, Gadegbeku B, Rufon A, Jenkins LC, N’Diaye
A. Genitourinary injuries after trafc accidents. J Trauma Acute Care Surg.
2017;82(6):1087–93. https://doi.org/10.1097/ta.0000000000001448.
4. McGeady JB, Breyer BN.Current epidemiology of genitourinary trauma. Urol
Clin North Am. 2013;40(3):323–34. https://doi.org/10.1016/j.ucl.2013.04.001.
5. Voelzke BB, Leddy L.The epidemiology of renal trauma. Transl Androl Urol.
2014;3(2):143–9. https://doi.org/10.3978/j.issn.2223- 4683.2014.04.11.
6. EAU Guidelines. Edn. presented at the EAU annual congress Amsterdam, Mar 2022.
ISBN: 978-94-92671-16-5. https://d56bochluxqnz.cloudfront.net/documents/full-
guideline/EAU- Guidelines- on- Urological- Trauma- 2022_2022- 03- 24- 104100_
fwda.pdf.
7. Morey AF, Brandes S, Dugi DD 3rd, Armstrong JH, Breyer BN, Broghammer
JA, Erickson BA, Holzbeierlein J, Hudak SJ, Pruitt JH, Reston JT, Santucci RA,
Smith TG 3rd, Wessells H, American Urological Association. Urotrauma: AUA
guideline. J Urol. 2014;192(2):327–35. https://doi.org/10.1016/j.
juro.2014.05.004. Epub 2014 May 20.
8. Coccolini F, Moore EE, Kluger Y, etal. Kidney and uro-trauma: WSES-AAST guide-
lines. World J Emerg Surg. 2019;14:54. https://doi.org/10.1186/s13017- 019- 0274- x.
Anatomy oftheKidney
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Animal and human cadaveric dissection has been performed since antiquity, and the
oldest available illustration of the kidney is said to be a bronze gure found in the
Kition temples in Cyprus and dated to the thirteenth century BC [1]. The Italian artist Michelangelo (1475–1564) is reported to have had a strong interest in anatomy,
particularly in the kidneys, having participated in many dissections and having suffered from chronic nephrolithiasis. His portrayal of “God Separating the Earth from
Waters,” painted on the Sistine Chapel ceiling in Vatican City in 1511 and showing
the story of Genesis, is considered by analysts to represent kidney anatomy [2].
However, modern anatomy was born a few decades later, in the middle of the
sixteenth century AD, thanks to great anatomists and anatomopathologists such as
the Belgian Andreas Vesalius (1514–64) with his publication of “De Humani
Corporis Fabrica” (1543) and the Roman Bartolomeo Eustachio (1500 or
1510–1574) with his posthumous publication “Tabulae anatomicae Bartholomaci
Eustachii” [3, 4]. Eustachio was the rst to describe the adrenal glands and is also
credited for a great contribution to the modern knowledge of kidney anatomy: the
lower position of the right kidney compared with the left, the intrarenal kidney vasculature, the renal calyceal system and its relation to the renal papillae, and the renal
collecting ducts [1]. From the seventeenth century onward, many other contributors
did their bits for the development of kidney anatomy science: The Dutch Frederik
Ruysch (1638–1731), the Italian Lorenzo Bellini (1643–1704), the Dutch Govard
Bidloo (1649–1713), the Italian Giovanni Battista Morgagni (1682–1771), the
English William Cheselden (1688–1752), the Italian Marcello Malpighi
(1628–1694/8), and so on. [1]. The French anatomist Exupère Joseph Bertin
(1712–1781) is credited for the description of intra-renal septa in 1744 which
evolved later into the concept of “Columns of Bertin” and is also regarded by some
authors as the rst discoverer of the “Tubes of Henle” which he described as “petits
siphons recourbés” (small curved siphons) a century before the German anatomist
Friedrich Gustav Jakob Henle (1809–1885) [5, 6].
1
© The Author(s), under exclusive license to Springer Nature Singapore Pte
Ltd. 2023
S. A. AL-Mamari, Urogenital Trauma: A Practical Guide,
https://doi.org/10.1007/978-981-99-6171-9_1
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1 Anatomy oftheKidney
Because of the determination and sacrices of all these old anatomists and to the
continuous efforts of modern researchers, more detailed and precise knowledge is
available nowadays about the kidney. Hereafter, a practical summary is given to
help understand the basis of trauma management of this organ.
1.1 Embryology
The mesoderm which gives rise to the urinary tract appears on the 15th day of
development. Then the metanephros starts its growth during the fth week of
embryogenesis and starts its cranial migration in the following weeks to ultimately
form the denitive kidneys that have a dual mesodermal origin: The glomeruli and
tubules develop from metanephric blastema and the excretory segments (pelvi-
calyceal system) from the ureteric bud [7–9] (Figs.1.1 and 1.2).
During its ascent, the arterial supply of the metanephros also migrates cranially
with the following adaptation:
– At the most caudal initial stage: from the pelvic branches of the umbilical (iliac)
arteries
– Then from the sequential branches of the dorsal aorta
– At the most cranial nal stage: from a persistent lateral intersegmental artery of
the mesonephros, supplying also adrenal glands and gonads [7–10]
The embryological origin of accessory arteries is therefore considered the result
of persistent primordial arteries arising from more caudal sources during the ascent
(Fig.1.3a–d), but some authors considered them as the result of an early or precocious division of the renal artery [11, 12].
Fig. 1.1 Diagram of the
embryo depicting the
nephrotome, mesonephric,
and metanephric regions
from which the
pronephros, mesonephros,
and metanephros will,
respectively, arise. The
pronephros and
mesonephros will regress,
while the metanephros
develops into the
permanent kidney. (From
Kassab G.H. etal. [8], with
permission from Springer
Nature)
ab
cd
ef
1.1 Embryology
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Fig. 1.2 (a) Sketch of a lateral view of a 5-week embryo showing the extent of the mesonephros
and the primordium of the metanephros or permanent kidney. (b) Transverse section of the embryo
showing the nephrogenic cords from which the mesonephric tubules develop. Observe the position
of the urogenital ridges and nephrogenic cords. (c–f) Sketches of transverse sections showing successive stages in the development of a mesonephric tubule between the 5th and 11th weeks. Note
that the mesenchymal cell cluster in the nephrogenic cord develops a lumen, thereby forming a
mesonephric vesicle. The vesicle soon becomes an S-shaped mesonephric tubule and extends laterally to join the pronephric duct, now renamed the mesonephric duct. The expanded medial end of
the mesonephric tubule is invaginated by blood vessels to form a glomerular capsule (Bowman
capsule). The cluster of capillaries projecting into this capsule is the glomerulus. (From Zweyer M
[9], with permission from Springer Nature)
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abcd
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Fig. 1.3 (a–d) Diagrammatic ventral views of the abdominopelvic region of embryos and fetuses
(sixth to ninth weeks) showing medial rotation and “ascent” of the kidneys from the pelvis to the
abdomen. (a, b) Observe also the size regression of the mesonephroi. (c, d) Note that, as the kidneys “ascend,” they are supplied by arteries at successively higher levels and that the hilum of the
kidney (where the vessels and nerves enter) is eventually directed anteromedially. (From Zweyer
M [9], with permission from Springer Nature)
1 Anatomy oftheKidney
1.2 General Aspects
The kidneys are reddish-brown bean-shaped paired retroperitoneal organs lying
obliquely on the posterior abdominal wall against the psoas and the quadratus lumborum muscles, exhibiting an angle of 30°–50° behind the coronal plane. As mentioned above, the right kidney is notoriously known to be inferiorly placed compared
with the left one since Eustachio’s descriptions, and the difference is 1–2cm. The
reason seems to be the presence of the liver above the right kidney. In addition, studies have shown that, in adults, the left kidney is larger than the right one, having a
mean length of 11.21–12.0cm and 10.97–11.4cm in adult males, respectively, and
a mean hilar thickness of 3.37cm and 3.21cm, respectively. Also, the upper pole
has a greater width than the lower pole in the same kidney, with values of 6.48cm
and 5.39cm, respectively [13–16].
The kidney weight steeply increases until the age of 20years, then continues
slowly to increase, reaching its maximum at the age of 30–40years with an average
of 318g for males and 255g for females, and then maintains a plateau until the age
of 50years before declining progressively [13].
1.3 General Structure andCoverings
The kidney is composed of a cortex, a medulla, and a pelvicalyceal system. The
cortex is the outer layer containing the glomeruli and convoluted tubules of the
functional units, namely, the nephrons, and the medulla is formed by pyramids
1.3 General Structure andCoverings
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Fig. 1.4 Kidney anatomy.
(From Blausen.com
[18]—CC BY 3.0 Creative
Commons Attribution
License)
7
containing the remaining parts of the nephrons: the loops of Henle and the collecting tubules. The cortex has projections that divide and limit the pyramids called
columns of Bertin. In some cases, the columns of Bertin increase in thickness and
form a mass that is made of glomerular tissues. These so-called cortical pseudotumors have sometimes been mistaken for vascular tumors [16–18] (Fig.1.4). Another
classical renal pseudotumor consists of a focal protrusion in the lateral border of the
midportion of the left kidney where the renal cortex is indented by the adjacent
spleen, the so-called dromedary hump [8].
More internally is the excretory system formed by the minor and major caly-
ces, which merge toward the hilum to form the renal pelvis in close contact with
the renal vessels. The topography of these structures at the renal hilum is well
known by the mnemonic VAP from anterior to posterior: the renal vein, the renal
artery, and the renal pelvis.
The kidney surface is covered with a renal capsule, surrounded by the perirenal
fat, which is enclosed by the brous Gerota’s fascia. The Gerota’s fascia, also simply called renal fascia, is surrounded anteriorly and posteriorly by the pararenal fat
[14]. The Gerota’s fascia comprises two layers: a strong posterior layer and a delicate anterior layer. The two layers fuse superiorly above the adrenals, laterally
behind the ascending and descending colons, and medially to adjacent fascia and
vessels, but they only touch each other inferiorly with no fusion [14, 15]. The posterior leaves of the diaphragm arch as a dome above the superior pole of the kidneys.
The pleura lines the thoracic side of this dome and extends posteriorly and inferiorly
up to the 12th rib, being therefore exposed to punctures during nephrostomy or
injuries during the lumbar approach to nephrectomy [14, 15].
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1 Anatomy oftheKidney
1.4 Anatomical Relations
The kidneys are in close contact with [15–17]:
– Postero-superiorly (upper third): the diaphragm.
– Superiorly: the suprarenal gland.
– Medially: the inferior vena cava (IVC), the head of the pancreas (hilar level) on
the right side, and the aorta and body of the pancreas (hilar level) (on the left side).
– Antero-superiorly: the liver, the right colonic exure on the right side, the stom-
ach, the spleen, the jejunum, and the left colonic exure on the left side.
– Antero-medially: the second and third part of the duodenum on the right side,
and the pancreas on the left side.
– Posteriorly: the subcostal, the ilioinguinal, and the iliohypogastric nerves, the
quadratus lumborum, and the psoas muscles.
– Lateral to the psoas muscle: The abdominal wall is built of the transversal, inter-
nal, and external oblique muscles.
– Posterior to the 12th rib: the latissimus dorsi and slips of the serratus posterior
inferior muscle.
The kidneys are situated at an average depth of 4–5cm from the skin of the back.
When approaching it through a lumbar incision, the following structures will be
encountered in progressive order from posterior to anterior: skin, subcutaneous
tissue, subcutaneous latissimus dorsi, serratus posterior inferior (often difcult to
detect), the lateral border of the erector spinae (iliocostalis, longissimus, and spinalis), the external oblique, the internal oblique, and the transversus abdominis
muscles, whose posterior aponeurosis contributes to the thoracolumbar fascia, the
quadratus lumborum muscle (located between the iliac crest and the 12th rib, immediately lateral to the transverse processes of lumbar vertebrae), and the pararenal
fat that covers the kidneys [16, 19] (Fig.1.5).
a
Erector spinaePsoas major
1.5 Arterial Supply andVenous Drainage
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Fig. 1.5 Schematic
sagittal and transverse
Eleventh rib
sections of the right kidney
showing the renal fascia
and its relationship to the
Twelfth rib
Liver
peritoneum and posterior
abdominal wall. (From
Mahadevan, V. [16] 2019,
with permission from
Elsevier)
Posterior lamina
of renal fascia
Anterior lamina
of renal (Gerola’s
fascia
Peritoneum
Vessel of
renal hilum
Right colic
flexure
b
Rectus abdominis
External oblique
Internal oblique
Transversus
abdominis
Fascia
transversalis
Peritoneum
Colon
Anterior
lamina of
renal fascia
Kidney
Perirenal fat
1.5 Arterial Supply andVenous Drainage
Together the two kidneys receive more than 1.2L of blood per minute, representing
more than 20% of the total cardiac output. The renal arteries arise from the lateral
sides of the abdominal aorta at the L1–L2 level, more precisely at the lower third of
L1, immediately caudal to the origin of the superior mesenteric artery, and usually
Quadratus lumborum
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