Urological-Trauma-2026

Aim and Objectives of the EAU Urological Trauma Guidelines

• The primary aim of these guidelines, prepared by the European Association of Urology (EAU) Guidelines Panel, is to assist medical professionals in the management of urological trauma in adults.
• Paediatric urological trauma is not covered in this document but is addressed separately in the EAU Paediatric Urology Guidelines.
• These guidelines represent the best available evidence and should support, not replace, clinical expertise and individual patient values or circumstances.
• The guidelines are not mandates and do not establish a legal standard of care.

Methodology and Evidence Strength Rating

• Panel Composition: The panel consists of an international group of urologists and an interventional radiologist.
• Evidence Sources: A systematic literature search was conducted for the 2025 update across Medline, EMBASE, and Cochrane Libraries, covering the period from 29 April 2022 to 1 May 2024. A total of $2,708$ unique records were screened.
• Limitations: The majority of publications identified were case reports and retrospective case series. There is a lack of high-powered randomized controlled trials (RCTs) in the field of urological trauma.
• Strong Recommendations: Typically indicate a high degree of evidence quality ($LE$) or a clearly favorable balance between benefit and harm.
• Weak Recommendations: Typically reflect lower-quality evidence or an equivocal balance between benefit and harm.

Global Epidemiology and Classification of Trauma

• WHO Definition: Injuries (trauma) are one of the three largest global causes of death and disability, alongside communicable and noncommunicable diseases.
• Global Statistics: In 2019, injuries accounted for nearly $4.5$ million deaths, representing approximately $8\%$ of all deaths globally. Trauma is responsible for an estimated $10\%$ of all years lived with disability.
• Sex Distribution: Death from injury is twice as common in males, predominantly due to road traffic accidents, self-harm, and interpersonal violence.
• Age and Income Factors: Nearly $1.9$ million trauma deaths occur annually in those aged 15-49 years. Road traffic injuries are a top-ten cause of death in low- and middle-income countries, but not in high-income countries.
• Classification by Intent:
  • Intentional: Interpersonal violence, war-related, or self-inflicted (accounts for over one-quarter of trauma deaths).
  • Unintentional: Road traffic accidents, falls, and domestic accidents.
  • Iatrogenic: Injuries occurring during therapeutic or diagnostic procedures by healthcare personnel.
• Classification by Mechanism:
  • Penetrating: When an object pierces the skin.
    • High-velocity projectiles: (e.g., rifle bullets) $800-1000\,\text{m/sec}$. These cause expansive cavitation destroying areas larger than the projectile tract.
    • Medium-velocity projectiles: (e.g., handgun bullets) $200-300\,\text{m/sec}$.
    • Low-velocity items: (e.g., knife stabs). Damage is usually confined to the projectile tract.
  • Blunt: Crushing or deceleration injuries.
  • Blast Injury: Complex trauma involving blunt and penetrating mechanisms plus burns.

General Management Principles and Damage Control

• Trauma Centralization: Polytrauma management in major trauma centres by dedicated teams has been shown to reduce mortality by $25\%$ and decrease the length of stay by four days.
• The Lethal Triad: Damage control strategies aim to avoid the synergistic effects of hypothermia, coagulopathy, and acidosis.
• Phases of Damage Control:
  1. Phase 1: Rapid control of haemorrhage and wound contamination.
  2. Phase 2: Resuscitation in the ICU to restore temperature, coagulation, and tissue oxygenation.
  3. Phase 3: Definitive surgery and reconstruction in a stabilized patient.
• Mass Casualty Triage: Triage involves differentiating the few critically injured who can be saved by immediate intervention from those for whom treatment can be delayed and those whose survival is unlikely.
• Thromboprophylaxis: Trauma patients are at high risk for Deep Venous Thrombosis (DVT). Measures like compression stockings and low molecular weight heparins are recommended, though evidence for reducing mortality or pulmonary embolism is not high.
• Bed Rest: In isolated renal trauma, the practice of strict bed rest is waning for patients who can mobilize, as the risk of secondary haemorrhage is low.
• Antibiotic Stewardship: Indicated by injury grade and need for intervention. Local antimicrobial policies should guide use, even in cases of urinary extravasation where evidence for prolonged use is lacking.

Renal Trauma: Epidemiology and Classification

• Incidence: Renal trauma occurs in up to $5\%$ of all trauma cases, with a population incidence of $4.9$ per $100,000$. It is most common in young males.
• AAST Renal Injury Grading Scale ($2018$ update detail):
  • Grade 1: Subcapsular non-expanding haematoma and/or parenchymal contusion without laceration.
  • Grade 2: Non-expanding perirenal haematoma (Gerota’s fascia); laceration $< 1\,\text{cm}$ depth without extravasation.
  • Grade 3: Laceration $> 1\,\text{cm}$ without collecting system rupture or extravasation; vascular injury/active bleeding contained in Gerota’s fascia.
  • Grade 4: Laceration into collecting system with urinary extravasation; renal pelvis laceration or complete UPJ disruption; segmental renal vein/artery injury; active bleeding beyond Gerota’s fascia; segmental or complete infarction without active bleeding.
  • Grade 5: Shattered kidney (loss of anatomy); main renal artery/vein laceration or avulsion of hilum; devascularized kidney with active bleeding.
• Note: For bilateral injuries up to Grade 3, advance the grade by one.

Evaluation and Diagnosis of Renal Injury

• Clinical Indicators: Flank pain, abrasions, fractured ribs, abdominal distension, and visible or non-visible haematuria. Major injuries (UPJ disruption, pedicle injuries) may present without haematuria in some cases.
• Imaging Criteria:
  • Visible haematuria.
  • Non-visible haematuria with one episode of hypotension.
  • History of rapid deceleration injury.
  • Clinical signs: flank tenderness or palpable mass.
• Computed Tomography (CT): The modality of choice. Ideally performed as a three-phase study:
  • Arterial Phase: Assesses vascular injury and active extravasation.
  • Nephrographic Phase: Demonstrates parenchymal lacerations and contusions.
  • Delayed Phase (5 mins): Identifies collecting system or ureteric injury.
• Ultrasonography: Focused Assessment Sonography in Trauma (FAST) is used for hemoperitoneum detection but is insensitive for defining solid organ injuries.

Management of Renal Trauma

• Nonoperative Management (Conservative): The treatment of choice for stable patients (Grades 1–3 and most Grade 4). Includes bed rest, serial blood tests, and monitoring.
• Selective Angioembolisation (SAE): Indicated by CT findings of active contrast extravasation, arteriovenous fistula (AVF), or pseudoaneurysm. Success rates: $94.9\%$ for Grade 3, $89\%$ for Grade 4, and $76\%$ for Grade 5. Large perirenal haematoma ($> 25\,\text{mm}$ depth) predicts the need for SAE.
• Penetrating Injuries: Stab wounds posterior to the anterior axillary line in stable patients can often be managed nonoperatively. Gunshot wounds are independent risk factors for nephrectomy.
• Surgical Indications:
  • Persistent haemodynamic instability.
  • Expanding or pulsatile perirenal haematoma at laparotomy.
  • Grade 5 vascular injuries.
• Surgical Techniques:
  • Approach: Transperitoneal is standard.
  • Cattell-Braasch Manoeuvre: Medial visceral rotation to access the great vessels and renal vasculature. Involves incising the white line of Toldt and mobilizing the caecum/ascending colon.
  • Renorrhaphy: Most common reconstruction; watertight closure of the collecting system is preferred.
  • Nephrectomy: Historically occurred in $30\%$ of explorations, but can be up to $85\%$ when opening Gerota’s fascia in zone II.

Ureteral Trauma

• Epidemiology: Relatively rare ($1-2.5\%$ of urinary tract trauma) due to protection by the musculoskeletal system.
• Aetiology:
  • Iatrogenic: Responsible for the majority of cases ($> 75\%$ in many series). Gynaecological surgery is the most common cause, followed by colorectal and urological procedures.
  • External: Gunshot wounds are common in penetrating cases; deceleration leads to pelvi-ureteral disruption.
• Diagnosis: Often delayed. Hallmarks include flank pain, urinary leakage from drains, fever, or urinoma. CT urography is the best method; extravasation in the delayed phase is pathognomonic.
• Management Strategies:
  • Immediate Recognition: Primary repair (uretero-ureterostomy) is advised. Stenting (rendezvous technique or standard insertion) is crucial.
  • Upper Third Injury: Uretero-ureterostomy or transureteroureterostomy.
  • Mid Third Injury: Uretero-ureterostomy or Boari flap (L-shaped bladder flap).
  • Lower Third Injury: Ureteral re-implantation (ureteroneocystostomy) with a Psoas hitch.
  • Long Segment Loss: Ileal interposition graft, downward nephropexy, or auto-transplantation.

Bladder Trauma

• Non-iatrogenic (NIBT): Associated with pelvic fractures in $60-90\%$ of cases. Injury occurs in $3\%$ of all pelvic fractures and up to $26.5\%$ of severe pelvic injuries.
• Classification:
  • Extraperitoneal ($22.4-61.1\%$): Usually shearing near the bladder base; associated with pelvic ring displacement $> 1\,\text{cm}$ or pubic symphysis diastasis.
  • Intraperitoneal ($38.9-65.8\%$): Blow to a distended bladder, usually rupturing the bladder dome (the weakest point).
• Diagnosis: Visible haematuria and pelvic fracture are absolute indications for imaging. CT cystography requires retrograde filling with $300-350\,\text{mL}$ of contrast; passive filling (clamping catheter) is insufficient.
• Management:
  • Extraperitoneal: Conservative (catheter drainage) unless bone fragments penetrate the wall or the bladder neck is involved.
  • Intraperitoneal: Surgical repair is mandatory to prevent peritonitis and sepsis.

Urethral Trauma

• Anterior Male Urethral Injury: Most common site is the bulbar urethra (straddle injuries). Iatrogenic injury is common ($6.2-13.4$ per $1,000$ catheters). Clinical sign: Blood at the meatus.
• Posterior Male Urethral Injury: Pelvic Fracture Urethral Injuries (PFUI). Typically managed by suprapubic catheter ($SPC$) diversion followed by deferred