EAU 2025 Guidelines: Urological Trauma

What This Guideline Covers

The EAU 2025 Urological Trauma guideline provides evidence-based recommendations across 5 topic areas. The key (Strong-rated) recommendations are summarised below; the complete recommendation tables — including Weak recommendations with their strength ratings — plus classification and evidence tables are in the Full Guidelines tab.

Key Recommendations at a Glance

Every Strong-rated EAU recommendation. Where the guideline labels its sections, they are used as sub-headings.

• Assess haemodynamic stability upon admission.

• Record past renal surgery, and known pre- existing renal abnormalities (ureteropelvic junction obstruction, solitary kidney, urolithiasis).

• Test for haematuria in a patient with suspected renal injury.

• Perform a multiphase computed tomography (CT) scan in trauma patients with: • visible haematuria; • non-visible haematuria and one episode of hypotension; • a history of rapid deceleration injury and/or significant associated injuries; • penetrating trauma; • clinical signs suggesting renal trauma e.g., flank pain, abrasions, fractured ribs, abdominal distension and/or a mass and tenderness.

• Manage stable patients with blunt renal trauma non-operatively with close monitoring and re-imaging as required.

• Manage isolated Grade 1-4 stab and low- velocity gunshot wounds in stable patients non-operatively.

• Use selective angioembolisation for active renal bleeding if there are no other indications for immediate surgical exploration.

• Insert urinary system drainage (ureteral stenting, nephrostomy) or perirenal drainage in cases of persistent or symptomatic urinary leak.

• Proceed with renal exploration in the presence of persistent haemodynamic instability due to renal injury after failure of non-operative management.

• Perform renal exploration in case of expanding or pulsatile peri-renal haematoma during laparotomy for associated injuries.

• Repeat imaging in high-grade and penetrating injuries and in cases of fever, worsening flank pain, or falling haematocrit.

• Visually identify the ureters to prevent ureteral trauma during complex abdominal and pelvic surgery.

• Beware of concomitant ureteral injury in all abdominal penetrating trauma, and in deceleration-type blunt trauma.

• Repair iatrogenic ureteral injuries recognised during surgery immediately.

• Treat iatrogenic ureteral injuries with delayed diagnosis by nephrostomy tube/JJ stent urinary diversion.

• Manage ureteral strictures by ureteral reconstruction according to the location and length of the affected segment.

• Perform cystography in the presence of visible haematuria and pelvic fracture.

• Perform cystography in case of suspected iatrogenic bladder injury in the post- operative setting.

• Perform cystography with active retrograde filling of the bladder with dilute contrast (300-350 mL).

• Perform cystoscopy to rule out bladder injury during retropubic sub-urethral sling procedures.

• Manage blunt extraperitoneal bladder injuries operatively in cases of bladder neck involvement and/or associated injuries that require surgical intervention.

• Manage blunt intraperitoneal injuries by surgical exploration and repair.

• Perform cystography to assess bladder wall healing after repair of a complex injury or in case of risk factors for wound healing.

• Provide appropriate training to reduce the risk of traumatic catheterisation.

• Evaluate male urethral injuries with flexible cysto-urethroscopy and/or retrograde urethrography.

• Evaluate female urethral injuries with cysto-urethroscopy and vaginoscopy.

• Treat iatrogenic anterior urethral injuries by transurethral or suprapubic urinary diversion.

• Treat partial blunt anterior urethral injuries by suprapubic or urethral catheterisation.

• Treat pelvic fracture urethral injuries (PFUIs) in hemodynamically unstable patients initially by transurethral or suprapubic catheterisation.

• Do not repeat endoscopic treatments after failed re-alignment for male PFUI.

• Treat partial posterior urethral injuries initially by suprapubic or transurethral catheter.

• Do not perform immediate urethroplasty (< 48 hours) in male PFUIs.

• Manage complete posterior urethral disruption in male PFUIs with suprapubic diversion and deferred (at least three months) urethroplasty.

• Perform early repair (within seven days) for female PFUIs (not delayed repair or early re-alignment).

• Exclude urethral injury in the case of penile fracture.

• Perform ultrasound (US) for the diagnosis of testis trauma.

• Treat penile fractures surgically, with closure of tunica albuginea.

• Explore the injured testis in all cases of testicular rupture and in those with inconclusive US findings.