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Damage Control in Genitourinary Trauma

Damage control in genitourinary (GU) trauma is the abbreviated management of urinary tract injuries in a patient whose physiology cannot tolerate definitive repair. Hemorrhage and urinary contamination are controlled, urine is drained or diverted, and reconstruction is deferred until resuscitation has corrected hypothermia, acidosis and coagulopathy.[1] The approach comes from general trauma surgery: in a retrospective series of 46 patients with exsanguinating penetrating abdominal injury, survival was similar overall with damage control or definitive laparotomy (55% versus 58%), but in the 22 patients with major vascular injury and two or more visceral injuries it was 10/13 with damage control versus 1/9 with definitive laparotomy.[2] Michael Coburn applied the strategy to urologic injuries in 1997, describing temporizing procedures such as externalized stenting and drainage and the need for close communication between the trauma team and the surgical subspecialists.[3] Smith and Coburn later extended it to renal, ureteral, bladder, urethral and genital injuries, noting that in the critically injured patient these are often diagnosed intraoperatively with little or no preoperative imaging or staging.[4] The temporizing choice made at the index operation sets the starting point for later reconstruction.

Grading, imaging and definitive repair for each organ are on the organ pages: Renal Trauma, Ureteral Trauma, Bladder Trauma and Pelvic Fracture Urethral Injury. General damage-control physiology, vascular exposure and REBOA are covered in Vascular Management & Damage Control.

Principles​

The EAU describes damage control as three phases: rapid control of hemorrhage and wound contamination; resuscitation to restore temperature, coagulation and tissue oxygenation; and definitive surgery, when time-consuming reconstruction is performed in the stabilized patient. Complex reconstruction, including organ-preserving procedures, is not undertaken during the first phase, and the decision to enter damage-control mode is made by the lead trauma clinician after team discussion. Temporary urinary drainage by nephrostomy, suprapubic or urethral catheter is the usual urologic adjunct; the EAU cites the unstable patient with suspected renal hemorrhage, or with a pelvic fracture and associated bladder or urethral injury, as typical examples.[1] The AUA guideline likewise notes that immediate intervention for acute urologic injury often requires flexibility in accordance with damage-control principles in critically ill patients.[5]

Urologic priorities at a damage-control laparotomy follow that sequence:

  1. Hemorrhage. The kidney is the GU organ most likely to bleed enough to drive the decision. AUA requires immediate intervention (surgery, or angioembolization in selected situations) for hemodynamically unstable patients with no or only transient response to resuscitation (Statement 5a; Standard, Grade B), and its discussion directs patients who remain unstable despite active resuscitation to the operating room rather than to angiography.[5]
  2. Urine. Extravasation is controlled by drainage or diversion rather than repair. A Colombian trauma group consensus on penetrating renal and urinary tract injury holds that urinary tract injury is not an acute threat during damage control and that its management should be conservative and deferred; this is an institutional consensus, not a comparative study.[6]
  3. Deferral. The ACS guideline defers definitive ureteral repair when the patient is unstable or when injury complexity exceeds the capabilities of the trauma team, and describes a Boari flap as rarely used in the acute trauma setting, recommending a damage-control approach for such complex injuries.[7]
  4. Handover. The ACS performance-improvement criteria expect GU trauma protocols to include a pathway for unstable patients who need a damage-control laparotomy, with close communication between surgical services.[7]

Recognition at the Index Laparotomy​

Kidney. The ACS advises leaving a nonexpanding zone II retroperitoneal hematoma from blunt trauma undisturbed and obtaining CT after laparotomy if the patient is stable; a ruptured, pulsatile or expanding hematoma, or ongoing instability, is explored, and zone II hematomas after penetrating trauma may be explored.[7] The EAU reports nephrectomy in about 30% of renal explorations overall and in up to 85% when zone II Gerota's fascia is opened.[1] The contralateral kidney is palpated before the injured side is explored; an on-table IVP can confirm a functioning contralateral kidney but cannot exclude injury.[7]

Ureter. AUA calls for direct inspection of the ureters at laparotomy when injury is suspected and no preoperative imaging was obtained (Statement 9b; Clinical Principle).[5] In one center's series, 5 of 40 traumatic ureteral injuries (12.5%) were missed at laparotomy, and in that study's pooled analysis of published series nephrectomy followed 2.4% of injuries diagnosed early versus 18.4% of those diagnosed late (p = 0.0001).[8] The Colombian consensus advises against a systematic search for the ureter inside a hematoma during damage control, because of time and the risk of devascularizing the ureteral wall.[6] The two positions address different situations: the AUA statement applies when ureteral injury is suspected.

Bladder. WSES-AAST recommends direct inspection of the intraperitoneal bladder during emergency laparotomy for suspected bladder injury, whenever feasible (GoR 1C).[9]

Urethra. With hemodynamic instability, WSES-AAST postpones urethral investigation and places a suprapubic catheter, and the EAU postpones retrograde urethrography until the patient is stabilized.[9][1]

Temporizing Maneuvers by Organ​

Kidney​

  • Leave the hematoma. A nonexpanding zone II hematoma after blunt trauma is left closed and characterized by CT once the patient is stable.[7]
  • Perirenal packing. The EAU notes that tight packing of the renal fossa with laparotomy swabs may be needed to limit hemorrhage when the hematoma cannot be left undisturbed.[1] The Colombian consensus packs a large, nonexpanding perirenal hematoma without active bleeding without opening Gerota's fascia, also packs the fossa after a rapid renorrhaphy, partial resection or nephrectomy, leaves the abdomen open under negative pressure, and re-explores at 24 to 48 hours.[6] Packing has not been compared with immediate nephrectomy.
  • Vascular control. In a retrospective review of 92 renal injuries by Carroll, Klosterman and Jack McAninch, 11 (12%) required temporary vascular occlusion, which was not associated with more postoperative azotemia or mortality.[10] A randomized trial of 56 penetrating renal injuries found no difference in nephrectomy rate (31% versus 30%), transfusion or blood loss with hilar control before opening Gerota's fascia, and a nonsignificant increase in operative time.[11] The German polytrauma guideline states that temporary pedicle clamping before opening Gerota's fascia lowers blood loss and the nephrectomy rate, a claim the randomized trial does not support.[12] The renal page describes the medial and lateral exposures.
  • Nephrectomy. The ACS advises nephrectomy, without an attempt at salvage, for patients who are hemodynamically unstable or need ongoing resuscitation with blood and pressors, and for a shattered or avulsed grade V kidney found at exploration.[7] The German guideline notes that exploration in unstable patients ends in nephrectomy in most cases, while recommending organ preservation where the type and severity of injury and concomitant injuries allow (GoR B).[12]
  • Endovascular bridges. WSES-AAST states that selective balloon occlusion of the renal artery under fluoroscopy could bridge to definitive hemostasis (GoR 2B) and that REBOA may be used as a bridge in unstable patients (GoR 2B).[9] The later UK-REBOA trial randomized 90 patients with exsanguinating hemorrhage and found 90-day mortality of 25/46 with an emergency-department REBOA strategy versus 18/43 with standard care (OR 1.58, 95% credible interval 0.72–3.52); it was not specific to renal injury.[13] The German guideline describes proximal embolization of the main renal artery in severe multiple trauma or high operative risk as a definitive damage-control measure or as a bridge to interval nephrectomy.[12] A hybrid room allows exploration and angioembolization together in hemorrhagic shock.[7]
  • Angioembolization in the stabilized patient. In a National Trauma Data Bank cohort (266 angioembolization, 215 surgical repair), propensity-matched angioembolization was associated with lower odds of nephrectomy than surgical repair (OR 0.18, 95% CI 0.04–0.70). The comparison is observational and concerns initial management, not the unstable non-responder.[14]
  • Collecting system. A renal pelvis or collecting-system leak does not need repair during damage control. WSES-AAST considers delayed operative management for stable or stabilized patients whose renal pelvis injury cannot be managed endoscopically or percutaneously (GoR 2B).[9]

Ureter​

AUA permits management of ureteral injuries in unstable patients with temporary urinary drainage followed by delayed definitive management (Statement 10b; Clinical Principle). Its discussion names ureteral ligation with percutaneous nephrostomy, or an externalized ureteral catheter secured to the proximal end of the defect, with definitive repair once the patient has stabilized.[5] The ACS lists the following options:[7]

  • Cutaneous ureterostomy. The proximal ureter is exteriorized.
  • Ligation with nephrostomy. The ureter is ligated and a percutaneous nephrostomy tube placed.
  • Intubated ureterostomy. A ureteral stent, feeding tube or pediatric urethral catheter is secured into the proximal end of the injured ureter and externalized to a drainage device.
  • Intraperitoneal drainage. When instability precludes even these maneuvers, urine is allowed to drain temporarily into the abdomen and is removed by suction through a temporary abdominal closure device.

The EAU prefers ligation of the ureter with diversion, for example by nephrostomy, and later definitive repair in unstable patients.[1] WSES-AAST describes the same strategy in its discussion text; its graded recommendation is repair of ureteral injuries discovered at laparotomy (GoR 1C), which presumes a patient who can tolerate it.[9] The Colombian consensus ligates the ureter as distally as possible if this can be done quickly, obtains contrast CT once the patient is stable, and leaves the choice between a double-J stent and a nephrostomy to the urologist.[6] Ligation commits the patient to prompt nephrostomy drainage; the intraoperative consultation page covers the same maneuvers for iatrogenic injury.

In a retrospective single-center series of 57 traumatic ureteral injuries (96.5% penetrating, 98% with associated injuries), external diversion was used in 9 (16%), ligation in 2 and nephrectomy in 2; renal salvage was achieved in 49 of 51 survivors (96%), and no death was attributed to the ureteral injury.[15]

Bladder​

Intraperitoneal rupture from external trauma requires surgical repair (AUA Statement 15; Standard, Grade B). The AUA discussion accepts delay in a patient who cannot undergo immediate repair, such as the unstable patient, and asks that repair be expedited when medically feasible.[5] The ACS likewise delays intraperitoneal repair only to ensure hemodynamic stability and completion of other urgent evaluation, citing Smith and Coburn.[7][4]

  • Drainage during damage control. WSES-AAST states that urinary diversion with bladder and perivesical drains or external ureteral stents may be used for severe intraperitoneal rupture during damage-control procedures (GoR 1C). Its discussion also allows a urethral or suprapubic catheter as a temporary measure with postponed repair in the unstable patient.[9]
  • Rapid closure. The Colombian consensus closes the bladder, when possible, in a single running layer of absorbable suture with packing and a Foley catheter; with extensive bladder destruction in an unstable patient, it packs the pelvis, places a catheter and defers repair.[6]
  • Extraperitoneal rupture. Uncomplicated injury is treated with catheter drainage (AUA Statement 16; Recommendation, Grade C).[5] Repair during a laparotomy done for other injuries is considered when physiology allows. In a single-center retrospective registry (56 catheter drainage, 24 early cystorrhaphy), patients who did not have cystorrhaphy during a nonurologic operation had more urologic complications and longer ICU (9.0 versus 4.0 days) and hospital stays (18.9 versus 10.6 days).[16] In the multicenter MiGUTS cohort of 157 extraperitoneal injuries, significant complications occurred in 23% after catheter drainage and 19% after operative repair (p = 0.55); concomitant bladder neck or urethral injury was the only predictor of complications (RR 2.69).[17] Neither study addresses the patient in the damage-control phase.
  • Drainage after repair. AUA recommends urethral catheter drainage without a suprapubic tube after bladder repair (Statement 18; Standard, Grade B).[5]

Urethra​

  • Posterior (pelvic fracture) injury. The ACS states that an unstable patient with a complete urethral injury from pelvic fracture needs a suprapubic tube rather than a urethral catheter.[7] The EAU strongly recommends initial transurethral or suprapubic catheterization for pelvic fracture urethral injury in unstable patients, and WSES-AAST recommends immediate urinary drainage with delayed treatment (GoR 1C).[1][9] AUA recommends suprapubic tube placement as the preferred initial management for most pelvic fracture urethral injuries (Statement 20b; Recommendation, Grade C).[5]
  • Placing the suprapubic tube. In shock, a pelvic hematoma can displace the bladder and the bladder may be poorly filled. The EAU allows one gentle urethral catheter attempt by experienced personnel and, if there is difficulty, a suprapubic catheter under ultrasound guidance or under direct vision, for example during laparotomy for associated injuries.[1]
  • What not to do. The EAU strongly recommends against immediate urethroplasty (under 48 hours) for male pelvic fracture urethral injury.[1] AUA restricts primary realignment to hemodynamically stable patients (Statement 22; Option, Grade C), so realignment is not part of the damage-control phase; comparative realignment data are on the PFUI page.[5] The German guideline recommends treating a urethral rupture in the same session when surgery is needed for a pelvic fracture or another intra-abdominal injury (GoR B), without specifying the method.[12]
  • Penetrating anterior injury. AUA advises prompt repair of uncomplicated penetrating anterior urethral injury (Statement 24; Expert Opinion), but its discussion excludes the unstable patient, a surgeon without urethral expertise and extensive tissue loss.[5] The ACS defers repair in the unstable patient with suprapubic drainage, and notes that larger defects may need temporizing exteriorization of the urethra.[7] WSES-AAST describes marsupialization, a temporary suprapubic catheter and interval urethroplasty after more than 3 months when damage control is needed or the defect is too long for anastomosis.[9]

Summary by Organ​

OrganTemporizing optionsWhen to returnDefinitive repairEvidence
KidneyLeave nonexpanding blunt zone II hematoma; perirenal packing with temporary abdominal closure; nephrectomy without salvage attempt if unstable; selective balloon occlusion or angioembolization as a bridgeRelook after resuscitation (24–48 h in one consensus); CT once stableRenorrhaphy, partial nephrectomy or interval nephrectomy; see Renal TraumaAUA Standard (5a); ACS; EAU; WSES-AAST 2B; institutional consensus; one small RCT on vascular control; registries[5][7][1][9][6][11][14]
UreterLigation with nephrostomy; intubated (externalized) ureterostomy; cutaneous ureterostomy; intraperitoneal drainage as a last resortOnce stable, at relook or after transfer; no defined intervalLocation-based repair; see Ureteral TraumaAUA Clinical Principle (10b); ACS; EAU; single-center series[5][7][1][15]
BladderUrethral or suprapubic catheter with perivesical drains; external ureteral stents; rapid single-layer closure if feasibleIntraperitoneal repair as soon as medically feasibleTwo-layer or watertight closure with urethral catheter; see Bladder TraumaAUA Standard (15); WSES-AAST 1C; ACS[5][9][7]
UrethraSuprapubic tube (open at laparotomy or image-guided); one gentle urethral catheter attempt; marsupialization for penetrating anterior defectsUrethroplasty at least 3 months after injury; early repair only in selected stable patientsDelayed anastomotic urethroplasty; see PFUIEAU strong; AUA Recommendation (20b); WSES-AAST 1C[1][5][9]

Return and Definitive Repair​

No comparative study defines the interval between the damage-control operation and definitive GU repair. The Colombian consensus re-explores at 24 to 48 hours to unpack the renal fossa and reassess.[6] The ACS performs delayed ureteral reconstruction at a repeat exploration after resuscitation or refers the patient to a tertiary center with advanced urinary reconstructive expertise.[7] For male pelvic fracture urethral injury with complete disruption, the EAU strongly recommends suprapubic diversion with urethroplasty deferred for at least 3 months, and gives a weak recommendation for early urethroplasty (2 days to 6 weeks) only in selected stable patients with a short gap, a soft perineum and tolerance of the lithotomy position.[1] Once the patient is stable, staging follows the organ pages: CT with a delayed phase for the kidney and ureter, and retrograde cystography for the bladder. Transfer triggers are listed on the GU Injury Overview.

Outcomes​

Mortality after GU trauma reflects overall injury severity more than the renal injury itself, according to the EAU and the German guideline.[1][12] Registry analyses of nephrectomy conflict and share the same confounding by physiology:

  • In TQIP patients with penetrating grade III or IV kidney injury who underwent laparotomy within 24 hours (2,214 grade III, 2,669 grade IV; 2013–2021), 89% of grade III and 54% of grade IV injuries were managed without nephrectomy. After adjustment, nephrectomy for grade III injury was associated with higher mortality (prevalence ratio 1.53, 95% CI 1.06–2.20); for grade IV injury it was associated only with ICU admission.[18]
  • In a propensity-score TQIP analysis of 12,780 high-grade renal injuries (1,014 nephrectomies), unadjusted mortality was 10.6% after nephrectomy versus 4.2% without, but nephrectomy was not independently associated with mortality or acute kidney injury after adjustment for transfusion in the first 24 hours.[19]
  • In the National Trauma Data Bank (2017–2021), nephrectomy was preferred over kidney-preserving surgery when admission systolic pressure was below 90 mmHg (OR for kidney preservation 0.61). Kidney-preserving surgery was associated with more procedures for urine leakage (OR 1.40) but less acute kidney injury (OR 0.49) and hemodialysis (OR 0.32).[20]
  • In a single-center retrospective series of 153 grade IV renal injuries over 25 years, Buckley and McAninch reported an overall renal salvage rate of 84%; injuries with associated injuries requiring exploration were repaired with a 15% nephrectomy rate.[21]

Ureteral outcomes after temporizing diversion are reported mainly in single-center series; the 96% renal salvage figure above comes from one urban level I center.[15]

Evidence Gaps​

  • Temporizing strategies rest on guideline consensus, expert opinion and retrospective series. No study compares packing with nephrectomy, or ligation with nephrostomy against intubated ureterostomy.
  • The timing of return to the operating room is not defined by comparative data.
  • The only randomized evidence on renal vascular control is a single 56-patient trial in penetrating injury.[11]
  • REBOA data come from general trauma populations, and the one randomized trial raised concern for harm from an emergency-department strategy.[13]
  • Registry analyses of nephrectomy and mortality reach different conclusions and cannot fully adjust for physiology.[18][19]

See Also​

References​

1. Waterloos M, Campos-Juanatey F, Hallscheidt P, et al. EAU Guidelines on Urological Trauma. Limited update, March 2026. Sections 3.3.3 (damage control), 4.1.3.b (renal exploration), 4.2.4.a (ureter), 4.4.3.c and 4.4.5 (urethra). Guideline

2. Rotondo MF, Schwab CW, McGonigal MD, et al. "'Damage control': an approach for improved survival in exsanguinating penetrating abdominal injury." J Trauma. 1993;35(3):375–383. doi:10.1097/00005373-199309000-00008

3. Coburn M. "Damage control for urologic injuries." Surg Clin North Am. 1997;77(4):821–834. doi:10.1016/s0039-6109(05)70587-9

4. Smith TG 3rd, Coburn M. "Damage control maneuvers for urologic trauma." Urol Clin North Am. 2013;40(3):343–350. doi:10.1016/j.ucl.2013.04.003

5. Morey AF, Broghammer JA, Hollowell CMP, et al. Urotrauma Guideline 2020: AUA Guideline. J Urol. 2021;205(1):30–35. doi:10.1097/JU.0000000000001408. Full guideline, published 2014; amended April 2017 and August 2020.

6. Salcedo A, Ordoñez CA, Parra MW, et al. "Damage control for renal trauma: the more conservative the surgeon, better for the kidney." Colomb Med (Cali). 2021;52(2):e4094682. doi:10.25100/cm.v52i2.4682

7. American College of Surgeons Trauma Quality Programs. ACS TQP Best Practices Guidelines: Management of Genitourinary Injuries. Chicago, IL; August 2025. ACS guideline PDF

8. Kunkle DA, Kansas BT, Pathak A, Goldberg AJ, Mydlo JH. "Delayed diagnosis of traumatic ureteral injuries." J Urol. 2006;176(6 Pt 1):2503–2507. doi:10.1016/j.juro.2006.08.003

9. Coccolini F, Moore EE, Kluger Y, et al. "Kidney and uro-trauma: WSES-AAST guidelines." World J Emerg Surg. 2019;14:54. doi:10.1186/s13017-019-0274-x

10. Carroll PR, Klosterman P, McAninch JW. "Early vascular control for renal trauma: a critical review." J Urol. 1989;141(4):826–829. doi:10.1016/s0022-5347(17)41022-6

11. Gonzalez RP, Falimirski M, Holevar MR, Evankovich C. "Surgical management of renal trauma: is vascular control necessary?" J Trauma. 1999;47(6):1039–1042. doi:10.1097/00005373-199912000-00008

12. Ruf C, Kluth L, Wahlen S, Breuing J, Nestler T. "Initial surgical management of injuries to the urogenital tract in patients with polytrauma and/or severe injuries: a systematic review and clinical practice guideline update." Eur J Trauma Emerg Surg. 2025;51(1):182. doi:10.1007/s00068-025-02847-1

13. Jansen JO, Hudson J, Cochran C, et al. "Emergency department resuscitative endovascular balloon occlusion of the aorta in trauma patients with exsanguinating hemorrhage: the UK-REBOA randomized clinical trial." JAMA. 2023;330(19):1862–1871. doi:10.1001/jama.2023.20850

14. Hakam N, Amend GM, Nabavizadeh B, et al. "Utility and outcome of angioembolization for high-grade renal trauma management in a large hospital-based trauma registry." J Urol. 2022;207(5):1077–1085. doi:10.1097/JU.0000000000002424

15. Best CD, Petrone P, Buscarini M, et al. "Traumatic ureteral injuries: a single institution experience validating the American Association for the Surgery of Trauma-Organ Injury Scale grading scale." J Urol. 2005;173(4):1202–1205. doi:10.1097/01.ju.0000155526.37963.ef

16. Johnsen NV, Young JB, Reynolds WS, et al. "Evaluating the role of operative repair of extraperitoneal bladder rupture following blunt pelvic trauma." J Urol. 2016;195(3):661–665. doi:10.1016/j.juro.2015.08.081

17. Anderson RE, Keihani S, Moses RA, et al. "Current management of extraperitoneal bladder injuries: results from the Multi-Institutional Genito-Urinary Trauma Study (MiGUTS)." J Urol. 2020;204(3):538–544. doi:10.1097/JU.0000000000001075

18. Gomez M, Forssten MP, Neff LP, et al. "Contemporary management and outcomes of penetrating traumatic AAST-OIS grade III and IV kidney injuries undergoing laparotomy: a Trauma Quality Improvement Program analysis." Sci Rep. 2026;16(1):19164. doi:10.1038/s41598-026-47007-6

19. McCormick BJ, Horns JJ, Das R, et al. "Nephrectomy is not associated with increased risk of mortality or acute kidney injury after high-grade renal trauma: a propensity score analysis of the Trauma Quality Improvement Program (TQIP)." J Urol. 2022;207(2):400–406. doi:10.1097/JU.0000000000002253

20. Ito MA, Takahashi K, Burg ML, et al. "The role of kidney-preserving surgery in renal trauma: a nationwide analysis." Surgery. 2025;185:109505. doi:10.1016/j.surg.2025.109505

21. Buckley JC, McAninch JW. "Selective management of isolated and nonisolated grade IV renal injuries." J Urol. 2006;176(6 Pt 1):2498–2502. doi:10.1016/j.juro.2006.07.141