Management of Acute Urinary Leakage
For acute urinary leakage, immediate management should include urinary drainage with catheterization, followed by appropriate imaging to identify the source and extent of leakage, with definitive repair determined by the location and severity of the injury. 1
Initial Assessment and Management
Immediate Steps
- Urinary drainage: Place urinary catheter to divert urine from the site of leakage 1
- Assess hemodynamic stability: Monitor vital signs (pulse, blood pressure, temperature) to exclude shock and systemic infection 1
- Pain management: Provide analgesia as needed, preferably with NSAIDs such as diclofenac 75mg IM for rapid pain control 2
Diagnostic Workup
Laboratory assessment:
- Check serum creatinine and blood urea nitrogen levels
- Analyze drain fluid creatinine-to-serum creatinine ratio (DCSCR) - a drain creatinine level just 18% higher than serum creatinine potentially signifies urine leak 1
Imaging studies:
- CT urography with nephrographic and excretory phases (5-20 min after contrast) - gold standard for suspected ureteral injuries 1
- Ultra-low-dose CT cystography for suspected bladder injuries - more accurate than conventional cystography 3
- Ultrasound - can detect hydronephrosis or urinomas, but has lower diagnostic accuracy 1
Management Based on Injury Type
Ureteral Injuries
Intraoperative repair (if identified during surgery):
- Preferred option when urologic expertise is available 1
- For distal injuries: ureteroneocystostomy (with or without vesico-psoas hitch/Boari flap)
- For mid or proximal injuries: ureteroureterostomy
Postoperative management:
- Percutaneous nephrostomy with anterograde stent placement for retrograde stent failures 1
- For partial transections: minimally invasive techniques including wire recanalization and stent placement
Bladder Injuries
- Intraperitoneal injuries: Direct repair with 2-layer absorbable suture 1
- Urinary catheter: Maintain for at least 7 days
- Follow-up: Perform negative retrograde cystography before catheter removal 1
Post-Renal Surgery Leakage
- Ensure adequate drainage via catheter or stent
- Consider oral desmopressin therapy for persistent leakage when traditional approaches fail 4
Follow-up and Monitoring
Imaging Follow-up
- CT scan with delayed phase imaging is the method of choice for follow-up of ureteral and bladder injuries 1
- For moderate to severe renal injuries, contrast-enhanced CT scan with excretory phase within 48 hours after trauma 1
Monitoring Parameters
- Monitor urine output
- Track serum creatinine and BUN levels
- Assess drain output (if present)
- Watch for signs of infection (fever, increasing pain, leukocytosis)
Special Considerations
Minimally Invasive Surgery Complications
- If IUTI occurs during laparoscopic/robotic procedures:
- Perform laparoscopic/robotic repair if sufficient surgical expertise is available
- Consider "drain now, fix later" approach or conversion to open surgery if expertise is limited 1
Pitfalls to Avoid
- Delayed diagnosis: Can result in increased complications including urinomas, abscesses, strictures, fistulas, and potential kidney loss 1
- Misdiagnosis: Internal leakage of urine can mimic acute renal failure due to urine resorption into the blood 5
- Inadequate drainage: Failure to establish proper urinary diversion can worsen outcomes
By following this structured approach to acute urinary leakage management, clinicians can minimize complications and improve patient outcomes through prompt diagnosis, appropriate drainage, and timely definitive repair when indicated.