Technique

After placing a Foley catheter, a scout film is obtained. The bladder should be distended via gravity; a useful technique is to remove the central piston from a 60 mL catheter-tip syringe, connect the catheter-tipped end to the Foley, and pour contrast into the syringe. The bladder should be filled to capacity: 400 mL in a person older than 11 years, or estimated by the formula “(age in years + 2)*30”. If the patient cannot tolerate this amount, the bladder should be filled to capacity and then 50 mL of contrast should be injected by hand. For conventional radiography, half-strength contrast is used (Cystografin 30 diluted with normal saline), and AP and oblique images are necessary to identify lateral or posterior injuries. For CT, contrast should be diluted to 3–5% (approximately 1:6) in order to avoid artifact; the entire pelvis should be imaged, and postdrainage films are not necessary.

Retrograde Urethrogram (RUG)

RUG is the preferred method for evaluation of a suspected urethral injury, and must be performed prior to Foley catheter placement if an injury is suspected. Proper positioning is essential to an adequate exam.61

Technique

The patient should be positioned in the 25–35° oblique position, with the bottom leg flexed at the hip and knee such that the femur is outside the exposed field. In patients with pelvic fractures, it may be difficult to achieve this position; in these cases supine or oblique films without flexion at the hip are acceptable, though not ideal. A nonlubricated 14or 16-French Foley catheter is placed into the urethra, just beyond the meatus. The balloon is inflated with 1–2 cc to ensure a good fit within the fossa navicularis.We typically tie an unfolded 4 × 4 around the glans to prevent leakage of contrast around the catheter and out the meatus, as this can obscure the exam.After obtaining a scout film,approximately 50–60 mL of half-strength Cystografin 30 is gently injected through the catheter, preferably during real-time fluoroscopy. If there is no extravasation, the catheter can be advanced to the bladder in order to perform a cystogram.

Retrograde Pyelogram (RPG)

Though often not practical in the acute trauma patient, RPG is the gold standard imaging modality for suspected ureteral injury.

Technique

A scout radiograph is obtained. The ureteral orifice is visualized cystoscopically and after removing air from the injection catheter and syringe, the ureteral orifice is intubated with a whistle-tip catheter and 5–10 cc of half-strength Renografin 60 is gently injected under real-time fluoroscopy. The entire collecting system and ureter should be visualized. Delayed images can be obtained to assess for drainage, but this is often not necessary in the trauma patient.

One-Shot IVP

In patients who are too unstable for abdominal CT, intraoperative one-shot IVP is a rapid, safe, and accurate tool for guiding decision-making following suspected renal and ureteral injury.

Technique

A bolus of 2 mL/kg Renografin 60 is given intravenously, either during resuscitation in the trauma bay or during laparotomy. A single plain abdominal radiograph is taken 10 min after injection. An additional plain film can be taken 20–30 min later if hypotension prevented adequate uptake by the kidneys or if ureteral opacification was incomplete.

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