Clinical Radiology (2001) 56: 268±277doi:10.1053/crad.2000.0629, available online at http://www.idealibrary.com on

Pictorial Review

The Role of CT in the Management of Adult UrinaryTract Trauma

TZE M. WAH, JOHN A. SPENCER

Department of Clinical Radiology, St. James's University Hospital, Leeds, LS9 7TF, U.K.

Received: 16 June 2000 Revised: 11 September 2000 Accepted: 27 September 2000

Computed tomography (CT) is now the investigation of choice for evaluating haematuria followingmajor abdominal trauma. This pictorial review provides a logical framework for understanding theclassi®cation and features of urinary tract injuries, de®nes the indications and outlines the techniques forCT imaging in upper and lower urinary tract trauma. The use of other competing imaging modalities isalso discussed. Wah, T. M. & Spencer, J. A. (2001) Clinical Radiology 56, 268±277.

# 2001 The Royal College of Radiologists

Key words: CT, kidneys, bladder, trauma.

INTRODUCTION

The clinical management of urinary tract trauma remainscontroversial. Despite variations in clinical practice, there isincreasing focus on computed tomography (CT) as the ®rstline investigation of haematuria following major abdominaltrauma. In this pictorial review we outline a framework forunderstanding the classi®cation and features of urinarytract injuries, and de®ne the indications and outline thetechniques for CT imaging in urinary tract trauma. Inaddition, we assess the current role of intravenousurography. Our aim is to provide a simple and e�ectivediagnostic imaging approach for urological injuries.

UPPER URINARY TRACT TRAUMA

Epidemiology

Following blunt and penetrating abdominal trauma,major renal injuries occur in 8±10% of patients [1,2]. Themajority of renal injuries are attributable to blunt trauma.However, the increasing violent crime rate in urban life hasresulted in a dramatic rise in penetrating injuries [3]. Mostblunt renal trauma results from road tra�c accidents, othercauses include contact sports, falls and assaults. The kidneymay be injured by a direct blow, torn by rapid acceleration-deceleration momentum, or lacerated directly by broken

lower ribs [4]. Renal trauma is often accompanied bydamage to other important organs. This is more commonwith penetrating renal trauma where 80% of patients haveother major organ damage [5] compared with only 20% ofpatients with blunt renal trauma [6]. Patients withunderlying renal abnormalities, such as hydronephrosis,renal ectopia, cysts or tumours are more susceptible toinjury [7].

CLASSIFICATION OF RENAL INJURIES

The Renal Injuries Classi®cation was originally estab-lished by the Organ Injury Scaling Committee of theAmerican Association for the Surgery of Trauma [8](Table 1). Federle et al. have adapted this surgical stagingclassi®cation for renal injury based upon observationswhich can be made from CT examination [9]. The Federlemodi®ed CT classi®cation for renal injuries is widely usedin the U.S.A. as a basic guide for clinical management(Table 2).

Grade 1 renal injuries (Figs 1±3) account for 75±98% ofall injuries [10]. Patients with grade 1 renal injuries do notwarrant speci®c treatment and are usually managedconservatively. Most patients with grade 2 renal injuries(Figs 3 and 4) can be managed successfully without surgicalintervention [11]. However, a higher incidence of late onsethypertension has been reported in patients with grade 2renal injuries who were managed conservatively [12]. Forgrade 3 renal injuries (Figs 5±7), traditionally, surgical

0009-9260/01/040268+10 $35.00/0 # 2001 The Royal College of Radiologists

Author for correspondence and guarantor of study: J.A. Spencer.Tel: 0113-2065462; Fax: 0113-2065092; E-mail: wilsonspencer@compuserve.com

PICTORIAL REVIEW 269

intervention has been the management of choice [13].However, if patients have reasonable preservation of therenal function with a stable haematoma and limited urineextravasation, a signi®cant proportion will heal withconservative management [14].

CLINICAL INDICATIONS FOR INVESTIGATINGRENAL TRAUMA

Prompt and accurate staging of renal trauma allowsappropriate management to be planned. Signi®cant renalinjuries are reported in 15±42% of patients who have onlymicroscopic haematuria following penetrating renal trauma(Fig. 7), imaging is mandatory for all such patients irrespec-tive of the severity of the haematuria [9]. Conversely, only1±2% of stable patients with microscopic haematuria afterblunt trauma have signi®cant renal injuries [15]. There is

still controversy regarding the clinical indications forinvestigating blunt renal trauma [15]. However, the authorsof the most published series agree on several key clinicalindications for investigating patients with blunt renaltrauma [16±19] (Table 3).

IMAGING TECHNIQUES

Computed Tomography (CT)

In assessing renal trauma, CT has greater sensitivity andspeci®city than intravenous urography [20]. Contrastenhanced CT provides better de®nition of the type andextent of renal injuries and improves detection of contrastmaterial extravasation from the collecting system [14]. CT isalso superior to other imaging investigations in detectingunderlying renal disease in the traumatized kidney. CT isnow the preferred ®rst line investigation for acute urinary

Fig. 1 ± Axial CT section showing Grade 1 renal injury with a sub-capsular collection of blood (arrow) compressing the lateral aspect ofleft renal parenchyma.

Fig. 2 ± Axial CT section showing a Grade 1 segmental renal infarctionwith a sharply demarcated area of non-opaci®cation involving thepostero-medial aspect of the left kidney (arrow) following blunt renaltrauma.

Table 1 ± Renal injuries classi®cation by the Organ Injury ScalingCommittee

Grade Injury description for the organ injury scaling

1 a. Renal contusionsb. Subcapsular haematoma without parenchymal laceration

2 a. Con®ned perirenal haematomab. Super®cial renal laceration with 51 cm parenchymal

depth of renal cortex without urinary extravasation

3 a. Super®cial renal laceration with 41 cm parenchymaldepth of renal cortex without urinary extravasation

4 a. Deep renal laceration with parenchymal laceration withurinary extravasation

b. Minor vascular pedicle injuries with containedhaemorrhage

5 a. Completely shattered kidneyb. Major vascular pedicle injuries with avulsion of renal

hilum which devascularizes kidney

Table 2 ± CT classi®cation of renal trauma (after Federle [9])

Grade Renal injury Description

1 Minor a. Focal or global renal contusionb. Super®cial laceration that does not extend to

the collecting systemc. Small perirenal/subcapsular haematoma

(Fig. 1)d. Segmental ischaemic infarct (Fig. 2)

2 Major a. Deep lacerations of the renal parenchymalthat extend into the collecting system withlimited urine extravasation (Fig. 4)

b. Moderate to large perirenal/subcapsularhaematoma (Fig. 3)

3 Catastrophic a. Major renal pedicle injuries ± either renalartery/vein (Fig. 5)

b. Renal parenchymal fragmentation withextensive haemorrhage (Fig. 6)

c. Disruption of the renal pelvis or proximalureter (Fig. 7)

270 CLINICAL RADIOLOGY

tract trauma [21]. Commonly, assessment of the urinarytract is part of the general CT assessment of the abdomen inpatients with acute abdominal trauma.

In our hospital, patients receive both 500 ml of 2%Gastrogra®n (Schering, Burgess Hill, U.K.) orally or viaNG tube and 150 ml intravenous non-ionic 300 mg/mlstrength contrast medium administered at 3 ml/s. HelicalCT with a pitch of 1 and breath-hold duration of 20 s isroutinely used. Kilovoltage (KvP) and milliAmperage(mAS) are varied according to patient and CT machine.Contiguous CT slices are acquired from the domes of thediaphragm to the iliac crest with 10 mm collimation. Initialabdominal examination is performed 65 s after the start ofthe contrast medium injection. The upper abdomen is thusexamined before excretion of urine into the collectingsystems. Thus if there is evidence of a renal injury it isessential that the kidneys are re-examined in the delayedphase, to avoid overlooking renal collecting system injury

Fig. 4 ± (a) Axial CT section showing Grade 2 renal injury with a deepleft posterior renal parenchymal laceration (arrow) extending into thecollecting system. (b) On the delayed axial CT section contrast-enhanced urine is seen leaking from the collecting system (curvedarrow) into the perirenal spaces anteriorly.

Fig. 3 ± (a) Axial CT section showing Grade 2 renal injury with a deeppostero-lateral renal parenchymal laceration extending into the renalpelvis of the left kidney (curved arrow) and (b) a large perirenalhaematoma (arrow) that displaced the left kidney anteriorly but nourine extravasation indicating an intact collecting system.

Table 3 ± Clinical indications for investigating patients with blunt renaltrauma

1 Gross haematuria

2 Microscopic haematuria and shock with systolic blood pressure590 mmHg

3 Microscopic haematuria with signi®cant associated injuries

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[14]. A further 10±15 min delay is required prior to re-examining the urinary tract to allow urine excretion toopacify the collecting system and to identify leaks. The CTappearances of renal trauma are summarized in Table 4.

Intravenous urography (IVU)

For many years, IVU was the diagnostic mainstay inpatients with urinary tract trauma and provided su�cientinformation in most patients with suspected renal trauma toguide clinical management [22]. It is widely available and isa simple and inexpensive test. The `one-shot' IVU has beentried and tested in patients needing immediate urologicalsurgery [23]. The recommended adult dose of contrastmedium is 100±150 ml of a 300 mg/ml of standard ionic/non-ionic contrast agent via bolus injection. This large doseof contrast medium is required to compensate for decreasedrenal perfusion and the dilution caused by intravenous

¯uids. For satisfactory results, systolic blood pressure mustbe maintained at 480±90 mmHg.

It remains a good screening test in patients with isolatedmicroscopic haematuria and no other evidence of organinjury that might prompt a CT examination [24]. However,diligence is required in the performance and interpretationof the trauma IVU and in some cases tomography (Fig. 8)is required to clarify whether a urinary leak is present andwhether it is inside or outside the kidney.

URETERIC TRAUMA

Ureteric injuries comprise less than 1% of all urologicaltrauma [25] and penetrating trauma account for most of theinjuries, with the majority at mid to lower ureter [26]. Blunttrauma is a rare cause, mainly seen in paediatric age group

Fig. 5 ± (a) Axial CT section showing a pseudoaneurysm (arrow) in aseverely injured (Grade 3) left kidney seen as a well-de®ned highattenuation area centrally within the kidney. (b) Renal angiogramshowing a blush of contrast material (curved arrow) centrally in the leftkidney and (c) following selective coil embolization (arrow).

272 CLINICAL RADIOLOGY

due to rapid deceleration injuries, with the majority avulsedat the uretero-pelvic junction [27].A high index of clinical suspicion is required for the

diagnosis of ureteric injury as 33% of the ureteric injuriesare not associated with haematuria. Preoperative diagnosticstudies have low sensitivity and direct exploration of theureter remains the most accurate diagnostic method [25,28].

LOWER URINARY TRACT TRAUMA

Epidemiology

Approximately 70% of patients with bladder injurieshave concurrent pelvic fractures [10]. Conversely, only

about 10% of patients sustaining pelvic fractures havebladder injuries [29]. The severity of pelvic injury correlateswell with the likelihood of bladder and urethral trauma[10,30]. Gross haematuria is a strong predictor of signi®cantbladder injury in the presence of pelvic fractures [31,32].Urethral injury, typically involving the proximal portion, isfound in up to 10% of major pelvic fractures in some series(Figs 9±11) [33]. Other series report up to 10% of patientswith major pelvic fractures have combined bladder andurethral injuries [34].

Fig. 6 ± Axial CT section showing Grade 3 severely injured and frag-mented right kidney with extensive perirenal and pararenal haema-toma. Fig. 7 ± Delayed axial CT section following gunshot injury showing

contrast-enhanced urine extravasation from left renal pelvis intoperirenal space posteriorly (arrow). Note also the exit wound (curvedarrow) and additional bullet in anterior abdominal wall (arrowhead).

Table 4 ± CT appearances of renal trauma

Grade Renal injury Description

1 Minor a. Renal contusion appears as focal/global renal enlargement with irregular/striate nephrogram or focally ill-de®ned areaof diminished enhancement

b. Perirenal/subcapsular haematoma (Fig. 1) appears as a low attenuation area that surrounds/resides within the renalcapsule

c. Super®cial laceration with disruption of collecting tubules results in focal area of renal parenchyma staining withcontrast enhanced urine

d. Segmental infarct (Fig. 2) appears as a focal, well-de®ned wedge-shaped, low attenuation area of parenchyma whichtends to involve the upper pole

2 Major a. Deep laceration (Fig. 4) of the renal parenchyma involving the collecting system appears as a linear low attenuation areaextending from cortex into the collecting system with contrast extravasation directly from the disrupted collecting system

b. Similar to 1(b) but larger (Fig. 3)

3 Catastrophic a. Major renal vessels injuries:1. Renal artery ± Active arterial bleeding appears as an area of high attenuation (Fig. 5) contrast material surrounded by

lower attenuation haematoma; it occurs before the urine excretion and has a density of � or 480 HU and is usuallywithin 10 HU of an adjacent artery. With occlusion or avulsion, the devascularized kidney is usually intact butsmaller, may be displaced laterally and may have cortical rim enhancement due to collateral ¯ow

2. Renal vein ± Active venous bleeding can result in extensive perinephric haematoma. Thrombosis may lead to anenlarged kidney with a delayed but progressively dense nephrogram

b. Renal parenchymal fragmentation `shattered kidney' appears as multiple fragments with surrounding perirenal andpararenal haematoma (Fig. 6)

c. Disruption of the renal pelvis/proximal ureter results in contrast extravasation into perirenal and both pararenal spaces(Fig. 7)

PICTORIAL REVIEW 273

CLASSIFICATION OF LOWER URINARY TRACTINJURIES

Bladder Trauma

a. Intraperitoneal Bladder Rupture

This constitutes about 10±20% of all bladder ruptures[10]. Intraperitoneal bladder rupture frequently occurs at theanatomically vulnerable bladder dome and is more commonwith a full bladder and blunt trauma [34]. Contrast materialextravasation from the bladder outlines the intraperitoneal

recesses of the pelvis, paracolic gutters and subhepaticspace (Fig. 12). Large intraperitoneal bladder ruptureusually results in a collapsed bladder appearance.

Intraperitoneal bladder rupture warrants surgical repair.

b. Extraperitoneal Bladder Rupture

Extraperitoneal bladder rupture accounts for 80±90% ofbladder ruptures; 12% of extraperitoneal bladder rupturesoccur concurrently with intraperitoneal bladder rupture[10]. The most frequent site of rupture is at the antero-lateral aspect of the bladder near its neck. Its aetiology isunclear but it may result from shearing forces with disrup-tion of the bladder's ligamentous attachments to the pelvic¯oor leading to bladder rupture [32]. Extravasated urineleaks into the extraperitoneal soft tissues creating a streakyappearance as it dissects through the fascial planes of theprevesical space of Retzius, abdominal wall, inguinal, thigh

Fig. 8 ± (a) Emergency IVU in a patient with microscopic haematuriaafter ¯ank trauma showing a stretched left upper pole infundibulum(arrowhead) and abnormal contrast material collection around centralcalyces (curved arrow). It is unclear wether this is intra/extra-renal and(b) nephrotomography con®rming disruption to the left central calyces(arrow) with intrarenal contrast material extravasation.

Fig. 9 ± (a) Ascending urethrogram performed showing contrastmaterial extravasation from the posterior urethra into the prostatic bed(arrow) and base of penis (curved arrow) with associated bilateralsuperior and inferior pubic rami fractures and (b) axial CT sectionshowing an extraperitoneal pattern of contrast material extravasation(arrow).

274 CLINICAL RADIOLOGY

and presacral/paravesical space (Figs 9, 10 and 13). Whenthe urogenital diaphgram is disrupted extravasated contrastmaterial may extend into the perineum (Fig. 11) and this isusually associated with posterior urethral tears.Some extensive injuries may require surgical intervention,

but most patients can be conservatively managed bycatheter drainage.

CLINICAL INDICATIONS FOR INVESTIGATINGLOWER URINARY TRACT TRAUMA

Morgan et al. reported positive predictors for bladderrupture as gross haematuria, pelvic fractures, unexplainedpelvic ¯uid or a combination of all three. The speci®c pelvicfractures that are usually associated with bladder ruptureare pubic rami fractures, pubic symphysis diastasis, sacralfracture, sacroiliac diastasis and iliac fracture [35]. Theclinical indications for investigating the lower urinary tractare outlined in Table 5.

Nowadays most bladder trauma should be investigatedwith CT cystography. However, the evaluation of anysuspected urethral injury with ascending urethrogramshould precede cystography.

CT CYSTOGRAPHY

In most cases of pelvic trauma the pelvis will have beenexamined in the vascular phase to evaluate possible visceraltrauma or vascular injuries associated with active bleeding.This may reveal unexplained intraperitoneal or extraper-itoneal ¯uid. As with the upper abdomen this phase of CTexamination occurs before urinary tract opaci®cation. CTcystography is an adjunct examination to contrast enhanced

Fig. 10 ± (a) Initial axial CT section at the level of perineum showingdisruption of the pubis symphysis with obturator space haematoma(curved arrow) and (b) delayed antegrade CT cystography showingcontrast extravasation anteriorly (curved arrow) indicating extraper-itoneal bladder rupture.

Fig. 11 ± (a) Axial CT section at the level of greater trochanter showingextraperitoneal bladder rupture with contrast material extravasationinto the groin (arrowhead) and perineum and (b) along the spermaticcord into left scrotal sac (arrowhead) when the urogenital diaphragm isdisrupted.

PICTORIAL REVIEW 275

CT and may be performed using either an `intravenous' [36](Fig. 10) or `retrograde' technique [37±39] (Table 6)(Figs 12 and 13). CT cystography is as accurate as con-ventional cystography in diagnosing bladder rupture.

It is essential to ensure adequate bladder distension.`Intravenous' bladder ®lling requires bladder distensionfrom urine and excreted contrast material. The urinarycatheter should be clamped as soon as clinicians havedetermined that there is satisfactory urine ¯ow. Even with

this manoeuvre in a shocked patient bladder opaci®cationand distension may be suboptimal.

Retrograde bladder ®lling to its maximum capacity with300±400 mls of 2±4% contrast material can avoid thisproblem [38,39]. Instillation of less than 250 ml of contrastmedium into the bladder can produce a false negativeexamination due to inadequate distension [10,31,32]. Someauthors believe that post-evacuation imaging allows bettervisualization of any subtle extravasation of contrastmaterial [31,36]. We do not routinely obtain post-evacua-tion images. There are logistic problems in some patientsand an emerging view that they provide no additionalinformation [35].

CT cystography has its own pitfalls and distinguishingintraperitoneal from extraperitoneal bladder rupture can bedi�cult. A particular problem occurs when posteriorly

Fig. 12 ± (a) Axial CT section at the level of iliac crest after retrogradeCT cystography showing intraperitoneal bladder rupture with contrastmaterial outlining the sigmoid colon (arrow) and intraperitonealrecesses of the pelvis. (b) Axial CT section lower down at the level ofsuperior acetabulum showing contrast material extravasation from thebladder posteriorly in the deepest recess of the rectovesical pouch(arrow).

Fig. 13 ± (a) Pelvic CT digital radiograph following retrograde CTcystography showing bilateral fractures involving both superior andinferior pubic rami and linear streaks of contrast material extravasationbilaterally adjacent to the base of the bladder (arrow) indicatingbladder rupture. (b) Axial CT section at the level of superior portion ofthe acetabulum showing extraperitoneal bladder rupture with contrastmaterial extravasation anteriorly from the bladder into the prevesicalspace of Retzius (arrowhead) and paravesical space (curved arrow).

Table 5 ± Clinical indications for investigating the lower urinary tract

1 Gross haematuria with concurrent bony pelvic fractures (otherthan an acetabular fracture)

2 Gross haematuria with unexplained pelvic ¯uid detected oninitial CT assessment

3 External evidence of perineal trauma e.g. inability to void,bleeding at the urethral meatus, elevation of prostate on digitalexamination and perineal haematoma [30]

276 CLINICAL RADIOLOGY

placed extraperitoneal contrast media (Fig. 12) appears tobe in continuity with dependent intraperitoneal ¯uid as theyare only separated by a thin layer of peritoneum [40].

OTHER COMPETING IMAGING TECHNIQUES

Ultrasonography is the ®rst-line screening test inevaluating patients with blunt abdominal trauma in Europeand Asia [41]. It is an e�cient, repeatable test and does notinterfere with the resuscitation process or subsequent CTexamination. However, it does not always detect parench-ymal injury [42]. Since it is not a de®nitive diagnostic test itis not widely used to assess patients with physical signs ofacute urinary tract injury. Furthermore, ultrasonographyhas lower sensitivity in evaluating retroperitoneal structures[43] and it provides limited information regarding renalfunction.Renal arteriography was formerly the key investigation

for assessment of renal trauma in the patient with abnormalurography. Both have now been largely superseded by CT.

CONCLUSIONS

CT is now the preferred examination for evaluating acuteurinary tract trauma. The clinical indications for contrastenhanced CT of the upper urinary tract are summarized inTable 7. An additional CT cystogram to assess potentialbladder injury is indicated when patients present with grosshaematuria in conjunction with pelvic fractures, anunexplained pelvic ¯uid collection on initial CT assessment

or evidence of perineal injury. Suspected urethral injuryshould be excluded prior to cystography. Urographyremains an appropriate investigation for the urinary tractin a clinically stable patient with isolated microscopichaematuria.

REFERENCES

1 Cass AS. Immediate radiological evaluation and early surgicalmanagement of genitourinary injuries from external trauma. J Urol1979;122:772±774.

2 McAninch JW, Federle MP. Evaluation of renal injuries withcomputerized tomography. J Urol 1982;128:456.

3 Hai MA, Pontes JE, Pierce JM Jr. Surgical management of majorrenal trauma: a review of 102 cases treated by conservative surgery.J Urol 1977;1187:7±9.

4 Mitchell JP. Urinary tract trauma. Bristol: Wright, 1984:6.5 Scott R Jr, Carlton CE Jr, Goldman M. Penetrating injuries of thekidney: an analysis of 181 patients. J Urol 1969;101:247±253.

6 Bretan PN, McAninch JW. Evaluation of renal trauma: indicationsfor computed tomography and other diagnostic techniques. In:Lytton B, Catalona WJ, Lipshultz LI, McGuire EJ, eds. Advancesin urology, Vol 1. Chicago: Year Book Medical, 1988:65.

7 Bower P, Paul J, Brosman SA. Urinary tract abnormalities present-ing as a result of blunt abdominal trauma. J Trauma 1978;18:719±722.

8 Moore EE, Shackford SR, Pachter HL, et al. Organ injury scaling:spleen, liver and kidney. J Trauma 1989;29:1664±1666.

9 Federle MP, Brown TR, McAninch JW. Penetrating renal trauma:CT evaluation. J Comput Assist Tomogr 1987;11:1026±1030.

10 Mirvis SE. Diagnostic imaging of urinary system following blunttrauma. Clin Imaging 1989;13:269±280.

11 Cheng DL, Lazan D, Stone N. Conservative treatment of Type 3renal trauma. J Trauma 1994;36:491±494.

12 Cass AS, Luxenberg M, Gleich P, Smith CS. Long term results ofconservative and surgical management of blunt renal lacerations.Br J Urol 1987;59:17±20.

13 Lang EK. Current concepts in the diagnosis of renal trauma.Contemp Diagn Radiol 1983;6:1±6.

14 Mirvis SE. Trauma. Radiol Clin North Am 1996;34(6):1225±1257.15 Hardeman SW, Husmann DA, Chinn HKW, Peters PC. Blunt

urinary tract trauma: identifying those patients who require radio-logical diagnostic studies. J Urol 1987;138:99±101.

16 Nicolaisen GS, McAninch JW, Marshall GA, et al. Renal trauma:re-evaluation of the indications for radiographic assessment. J Urol1985;133:183±187.

17 Mee SL, McAninch JW, Robinson AL, Auerbach PS, Carroll PR.Radiographic assessment of renal trauma: 10 year prospective studyof patient selection. J Urol 1989;141:1095±1098.

18 Eastham JA, Wilson TG, Ahlering TE. Radiographic evaluation ofadult patients with blunt renal trauma. J Urol 1992;148:266±267.

19 McAndrew JD, Corriere JN Jr. Radiographic evaluation of renaltrauma: evaluation of 1103 consecutive patients. Br J Urol 1994;73:352±354.

20 Bretan PN, McAninch JW, Ferderle MP, Je�rey RB. Computerizedtomographic staging of renal trauma: 85 consecutive cases. J Urol1986;136:561±565.

21 McAninch JW. Editorial: renal trauma. J Urol 1993;150:1778.22 Hessel SJ, Smith EH. Renal trauma: a comprehensive review and

radiological assessment. CRC Crit Rev Clin Radiol Nucl Med1974;5:251±293.

23 Pollack HM, Wein AJ. Imaging of renal trauma. Radiology 1989;172:297±308.

24 Wong L, Waxman K, Smolin M, Rypins E, Murdock M. The roleof IVP in blunt trauma. Journal Trauma-Inj Inf Crit Care1988;28(4):502±504.

25 Presti J, Carroll P, McAninch J. Ureteric and renal pelvic injuriesfrom external trauma: diagnosis and management. J Trauma-Inj InfCrit Care 1989;29:370±374.

26 Templeton PA, Mirvis SE, Whitley NO. Traumatic avulsion of theureter: CT correlation. J Comput Assist Tomogr 1988;12:159±160.

Table 6 ± Summary of techniques for CT cystography

Retrograde bladder®lling technique

Infusion of 4% contrast medium isadministered via indwelling Foley catheter. Atotal of 350 ml is infused unless contrastadministration is limited by detrusorcontraction [14]; 5 mm slices obtained throughthe bladder

`Intravenous' bladder®lling technique

Bolus intravenous injection of non-ioniccontrast medium with a clamped urinarycatheter. A delay of 15±30 min is required toallow bladder distension and opaci®cation byurinary excretion of contrast [37]

Table 7 ± Clinical indications for contrast enhanced CT of the upperurinary tract

1 Patients with gross haematuria with/without shock

2 Haemodynamically stable patients with microscopic haematuriawho have other indications for a contrast-enhanced CT scan of theabdomen and pelvis

3 Haemodynamically stable patients with microscopic haematuriawith clinical evidence of major blunt ¯ank trauma

4 Patients with any degree of haematuria following penetrating ¯ankinjuries

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27 Reznichek RC, Brosman SA, Rhodes DB. Ureteric avulsion fromblunt trauma. J Urol 1973;109:812±816.

28 Campbell EW, Filderman PS, Jacobs SC. Ureteric injury due toblunt and penetrating trauma. Urology 1992;40:216.

29 Carlton CE. Injuries of the kidney and ureter. In: Harrison JH,Giles RF, Perlmutter AD, eds. Campbell's Urology, 4th ed.Philadelphia: WB Saunders, 1978:881±905.

30 Mirvis SE, Dunham C. Abdominal/pelvic trauma. In: Mirvis SE,Young JWR, eds. Diagnostic imaging in Trauma and Critical care.Baltimore: Williams and Wilkins, 1992:148±242.

31 Sclafani SJA, Becker JA. Radiologic diagnosis of extraurinarytrauma. Urol Radiol 1985;7:201±210.

32 Spirnark JP. Pelvic fractures and injury of the lower urinary tract.Surg Clin North Am 1988;68:1057±1069.

33 Sandler CM, Harris JH, Corriere JN, Toombs BD. Posteriorurethral injuries after pelvic fracture. Am J Roentgentol 1981;137:1233±1237.

34 Sandler CM, Phillips JM, Harris JD, Toombs BD. Radiology ofthe bladder and urethra in blunt pelvic trauma. Radiol Clin NorthAm 1981;19:195±211.

35 Morgan DE, Nallamala LK, Kenney PJ, Mayo MS, Rue LW III. Tcystography: Radiographic and clinical predictors of bladderrupture. Am J Roentgentol 2000;174:89±95.

36 HorstmanWG, McClennan BL, Heiken JP. Comparison of CT andconventional cystography for detection of traumatic bladderrupture. Urol Radiol 1991;12:188±193.

37 Kane NM, Francis IR, Ellis JH. The value of CT in the detection ofbladder and posterior urethral injuries. Am J Roentgentol 1989;153:1243±1246.

38 Lis LE, Cohen AJ. CT cystography in the evaluation of bladdertrauma. J Comput Assist Tomogr 1990;14:386±389.

39 Peng MY, Parisky YR, Cornwell EE III, Radin R, Bragin S. CTcystography versus conventional cystography in evaluation ofbladder injury. Am J Roentgentol 1999;173:1269±1272.

40 Scott MH, Porter JR. Extraperitoneal bladder rupture: pitfalls inCT cystography. Am J Roentgentol 1997;168:1232.

41 Bode PJ, Edwards MJR, Kruit MC, Van-Vugt AB. Sonography ina clinical algorithm for early evaluation of 1671 patients with bluntabdominal trauma. Am J Roentgentol 1999;172:905±911.

42 McKenney KL, Nunez DB, McKenney MG, Asher J, Zelnick K,Shipshak D. Sonography as the primary screening technique forblunt abdominal trauma: experience with 899 patients. Am JRoentgentol 1998;170:979±985.

43 Fernandez L, McKenny MG, McKenny KL, et al. Ultrasoundin blunt abdominal trauma. J Trauma Inj Inf Crit Care 1998;45:841±848.