• Holevar M, Ebert J, Luchette F, Nagy K, Sheridan R, Spirnak JP, Yowler C. Practice management guidelines for the management of genitourinary trauma. Winston-Salem (NC): Eastern Association for the Surgery of Trauma (EAST); 2004. 101 p. [129 references]

This is the current release of the guideline.

The levels of recommendation (I–III) and classes of evidence (I–III) are defined at the end of the "Major Recommendations" field.

1. Renal Trauma
   1. Level I

      There is insufficient Class I and Class II data to support any standards regarding management of renal trauma.

   2. Level II
      1. Preliminary vascular control does not decrease blood loss or increase renal salvage.
      2. Conservative management of shattered but perfused kidneys in hemodynamically stable patients with minimal transfusion requirements will result in a low incidence of complications, which can usually be treated with endourological or percutaneous methods.
   3. Level III
      1. Preliminary vascular control may prolong operative time.
      2. The success of nonoperative management may be enhanced by the use of angiographic embolization.
      3. Nonoperative treatment of renal lacerations from blunt trauma associated with extravasation is associated with few complications, which can usually be treated with endourological or percutaneous methods.
      4. Conservative management of major renal lacerations associated with devascularized segments is associated with a high rate of urologic morbidity (38 to 82%). In patients who present with a major renal laceration associated with devascularized segments, conservative management is feasible in those who are clinically stable with blunt trauma. The physician must be especially aware of the probable complications within this subset of patients.
      5. Operative exploration of the kidney should be considered in patients with major blunt renal injuries with a devascularized segment in association with fecal spillage or pancreatic injury.
      6. Nonoperative treatment of penetrating renal lacerations is appropriate in hemodynamically stable patients without associated injuries who have been staged completely with computed tomography (CT) scan and/or intravenous pyelogram (IVP). A high index of suspicion is needed to avoid ureteral injuries if a course of nonexploration is chosen.
      7. Penetrating Grade III or IV injuries are associated with a significant risk of delayed bleeding if treated expectantly. Exploration should be considered if laparotomy is indicated for other injuries or if the injury is not completely staged prior to exploratory laparotomy for other injuries.

2. Renovascular Trauma
   1. Level I

      There is insufficient Class I and Class II data to support any standards regarding management of renovascular trauma.

   2. Level II

      There is insufficient Class II data to support any recommendations regarding management of renovascular trauma.

   3. Level III

      There is insufficient Class III data to support any recommendations regarding management of renovascular trauma.

3. Ureteral Trauma
   1. Level I

      There is insufficient Class I and Class II data to support any standards regarding management of ureteral trauma.

   2. Level II

      There is insufficient Class II data to support any recommendations regarding management of ureteral trauma.

   3. Level III

      There is insufficient Class III data to support any recommendations regarding management of ureteral trauma.

4. Bladder Trauma
   1. Level I

      There is insufficient Class I and Class II data to support any standards regarding management of bladder trauma.

   2. Level II

      There is insufficient Class II data to support any recommendations regarding management of bladder trauma.

   3. Level III
      1. Conservative, nonoperative management of blunt extraperitoneal bladder rupture has a similar outcome to that of patients treated with primary suturing.
      2. Transurethral catheters result in fewer complications and fewer days of catheterization than suprapubic catheters, regardless of the degree of bladder injury, and are therefore preferable to suprapubic catheters whether the patient is being treated nonoperatively or operatively.

5. Urethral Trauma
   1. Level I

      There is insufficient Class I and Class II data to support any standards regarding management of urethral trauma.

   2. Level II

      There is insufficient Class II data to support any recommendations regarding management of urethral trauma.

   3. Level III

      Posterior urethral injuries secondary to blunt trauma may be treated either with delayed perineal reconstruction or primary endoscopic realignment, resulting in equivalent outcomes.

Definitions:

Recommendation Scheme

Level I: The recommendation is convincingly justifiable based on the available scientific information alone. This recommendation is usually based on Class I data; however, strong Class II evidence may form the basis for a Level I recommendation, especially if the issue does not lend itself to testing in a randomized format. Conversely, low quality or contradictory Class I data may not be able to support a Level I recommendation.

Level II: The recommendation is reasonably justifiable by available scientific evidence and strongly supported by expert opinion. This recommendation is usually supported by Class II data or a preponderance of Class III evidence.

Level III: The recommendation is supported by available data but adequate scientific evidence is lacking. This recommendation is generally supported by Class III data. This type of recommendation is useful for educational purposes and in guiding future clinical research.

Evidence Classification Scheme

Class I: Prospective randomized controlled trials

Class II: Clinical studies in which the data was collected prospectively, and retrospective analyses were based on clearly reliable data. Types of studies so classified include observational studies, cohort studies, prevalence studies, and case control studies.

Class III: Studies based on retrospectively collected data. Evidence used in this class includes clinical series and database or registry review.

None provided

Conclusions were based on evidence obtained from prospective, randomly assigned, double-blinded studies (Class I); prospective, randomly assigned, non-blinded studies (Class II); or retrospective series of patients or meta-analysis (Class III). The evidentiary tables included one Class I reference, four Class II references, and 123 Class III references.

The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").

• Holevar M, Ebert J, Luchette F, Nagy K, Sheridan R, Spirnak JP, Yowler C. Practice management guidelines for the management of genitourinary trauma. Winston-Salem (NC): Eastern Association for the Surgery of Trauma (EAST); 2004. 101 p. [129 references]

Not applicable: The guideline was not adapted from another source.

2004

Eastern Association for the Surgery of Trauma - Professional Association

Eastern Association for the Surgery of Trauma (EAST)

Eastern Association for the Surgery of Trauma (EAST) Practice Management Guidelines Work Group

Work Group Members: Michele Holevar, MD, Mount Sinai Hospital/Chicago Medical School; James Ebert, MD, Elmhurst Memorial Hospital; Fred Luchette, MD, Loyola University Medical Center; Kim Nagy, MD, John H. Stroger, Jr. Hospital of Cook County; Rob Sheridan, MD, Massachusetts General Hospital; J. Patrick Spirnak, MD, Case Western Reserve University; Charles Yowler, MD, Case Western Reserve University

Not stated

This is the current release of the guideline.

None available

This NGC summary was completed by ECRI on October 11, 2004.

This NGC summary is based on the original guideline, which is copyrighted by the Eastern Association for the Surgery of Trauma (EAST).