Upper Genitourinary (Kidney, Ureter) Trauma

Updated: Feb 16, 2024
  • Author: Sunny Mei-Chun Wang, MD, FACEP; Chief Editor: Trevor John Mills, MD, MPH  more...
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Overview

Practice Essentials

Genitourinary (GU) trauma accounts for about 10% of acute trauma in both the adult and pediatric populations. [1, 2] Although trauma is the leading cause of death in children and young adults and overall is the fifth leading cause of death in the United States [3] — and the 9th leading cause of death worldwide [4] — with the exception of high-grade renal trauma, GU trauma is rarely fatal. [5]  

GU injuries are rarely isolated and are often overlooked in trauma patients who present with multiple injured organs, especially considering that trauma care prioritizes life- and limb-threatening injuries. [6, 7] Coordinated efforts between various services caring for the patient are crucial to ensure comprehensive care, and evaluation of the injured patient with possible GU trauma should not differ from that of other trauma patients. The protocols of the Advanced Trauma Life Support (ATLS) program of the American College of Surgeons should be followed to provide total patient care. [8, 9, 10]

Kidneys are the most commonly injured GU organs; kidney injury occurs in about 1.2-3.3% of all trauma patients and 8-10% of patients with abdominal trauma. [11, 12]   In the US, 82-95% of renal injuries are secondary to blunt trauma. Motor vehicle accidents account for approximately 70% of blunt renal injuries, often as part of multi-organ injuries. [12, 13]  Sports-related blunt renal injury tends to have a different mechanism (a solitary blow to the flank), and therefore these patients may present with an isolated high-grade renal injury. [14]

The ureter is the least commonly injured GU organ. Ureteral injury accounts for 1-2.5% of all GU trauma and occurs in about 5% of penetrating abdominal trauma cases. [15, 16, 17]  However, a missed ureteral injury can lead to significant morbidity, with complications such as formation of urinomas, periureteral abscess, fistulas, and strictures. [15]  More severe complications include kidney failure, sepsis, and death. [15]

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Epidemiology

The frequency of GU injuries in the United States is as follows:

  • Renal Injuries: The incidence of renal injuries in trauma patients was 1.2%, with 14,000 patients hospitalized [15] ; 24% of all solid abdominal organ injuries involved the kidneys. [18]
  • Ureteral Injuries: Ureteral trauma occurs in less than 1% of genitourinary injuries. 
  • Adrenal injuries: Traumatic adrenal injuries disproportionately involve the right adrenal gland, with only the right adrenal gland being affected in more than 70% of cases. [19]
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Prognosis

With the exception of high-grade renal trauma, GU trauma is rarely fatal. [5]  GU injuries are rarely isolated and are often overlooked when trauma patients present with multiple injured organs, especially considering that trauma care prioritizes life- and limb-threatening injuries. [6, 7]  

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Anatomical Considerations

The kidneys, the pelvocaliceal system, and the ureters constitute the upper GU tract. Adult kidneys are relatively well protected by the rib cage, the back musculature, and the perinephric fat. However, kidneys are suspended from the renal pedicle without other firm attachments, so they are susceptible to injury from rapid deceleration or direct blow to the flank area. In addition, the vascular pedicles can be stretched during rapid deceleration, resulting in renal artery or vein injuries that can lead to thrombosis.

Children have less perinephric fat, thinner abdominal muscles, lack of ossification of the rib cage, larger kidney size relative to the rest of the body, and fetal kidney lobulations. Approximately 10% of children with blunt abdominal trauma will have a renal injury. [20]   Renal injuries account for only 3.5% of all pediatric GU injuries but are responsible for 25.7% of hospital admissions in this cohort. [16]

Pre-existing renal conditions (eg, hydronephrosis, calculi, cysts, tumors) increase the likelihood of renal injuries, even with low-velocity impacts. [21] A kidney with hydronephrosis or a cyst is a fluid-filled incompressible compartment and therefore more likely to amplify the force of trauma, resulting in injury.

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