Download MBBS Urology Presentations 13 Urological Trauma Lecture Notes

Download MBBS (Bachelor of Medicine, Bachelor of Surgery) 1st Year, 2nd Year, 3rd Year and Final year Urology 13 Urological Trauma PPT-Powerpoint Presentations and lecture notes

Urological Trauma

Urology

Trauma:

1. Given a patient with a potential urinary tract injury:

1. To list and interpret key clinical findings

2. To list and interpret critical investigations

3. Construct an initial management plan

4. To list and specify previous genitourinary anomaly.

Systems:

?

Renal

?

Bladder

?

Urethra

?

Ureter

?

External Genitalia


Renal Trauma Overview

? Most commonly injured GU organ
? 10% of all serious injuries abdominal have

associated renal injury

? Mode of injury

? Blunt renal truma

? MVA, fall from height, assaults

? Penetrating renal injuries

? Gunshots and stab wounds.

Hematuria and Renal Injury

? Best indicator of significant injury(microscopic

or gross)

? NOT related to the degree of injury
? Gross Hematuria is Variable and absent in :

? 7 % of grade IV renal injury
? 36% of renal vascular injury
? 50% of UPJ injuries
Whom to work up

? Penetrating trauma: EVERYONE
? Pediatric patients with microscopic hematuria.
? Blunt trauma: Image with CT if:

? gross hematuria
? microhematuria plus shock
? microhematuria plus acceleration/deceleration

Mee et al. (1989)

Hardeman et al (1987

Imaging of trauma patient with

hematuria

? CT preferred

? With contrast

? With "delayed" films (mandatory)

? Why not get CT cystogram too?

? Standard intravenous pyelogram (IVP): Forget

it

? "One Shot" intraoperative IVP

? 2 cc/kg intravenous contrast

? Single film at 10 minutes


Intraoperative One Shot IVP

? Allows safe

avoidance of renal

exploration in 32%

(Morey et al, 1999)

? Highly specific for

urinary

extravasation

? Confirms existence

of the other kidney

AAST Organ Injury Severity Scale for

the Kidney


AAST Organ Injury Severity Scale for

the Kidney

Indications for renal trauma surgery

? Absolute

? Hemodynamic instablity with shock

? Expanding /pulsatile renal hematoma

? Suspected renal pedicle avulsion (grade V)

? UPJ disruption

? Relative (now rare)

? Urinary extravasation with non viable tissue

? Renal injury together with colon /pancreatic injury

? Delayed diagnosis of arterial injury
Indications for angiography with

embolisation

? Bleeding from renal segmental artery
? Unstable condition with grade II or IV
? AV fistula or pseudoaneurysm
? Persistent gross hematuria
? Blood loss extending 2 units in 24 hrs.

Management Options For Renal

Trauma

? Close observation

? Bed rest

? Serial Hemoglobins

? Antibiotics if urinary extravasation

? Radiographic Embolization

? Urinary Diversion

? Ureteral Stenting

? Nephrostomy Drainage

? Surgery

? Renal Preservation / Reconstruction

? Nephrectomy
Surgical considerations

? Midline transabdominal approach
? Early vascular control before opening gerotas

fascia

? Landmark is IMA or in presense of large

hematoma ,IMV.

Renal trauma in pediatric population

? Kidneys propotinally larger and less protected
? Less retroperitoneal and peritoneal fat
? Less musculature
? Higher sympathetic tone ie hypotention less

reliable predictor of severity of renal injury.


Follow up

? Repeat CECT within 72 hrs
? Once pt is off hematuria and ambulatory

,discharged

? Adviced to avoid strenous activity for 4-6

weeks

? Follow up in opd after 3 weeks with USG and

Hgm.

Bladder Trauma
Bladder: BLUNT: Overview

? Rarely isolated
? 80 -90 % have severe associated injuries
? Often high-energy injuries
? Associated with urethral rupture 10-29% and

pelvic fracture 6-10%

Bladder: PENETRATING: Overview

? Incidence 2%

? Associated major abdominal injuries (35%)

and shock (22%)

? Mortality high: 12%
Bladder: Diagnosis: Physical Signs

?

Suspicion: required in cases of penetrating trauma, based

on trajectory

?

Physical signs:

?

Abdominal pain

?

Abdominal tenderness

?

Abdominal bruising

?

Urethral catheter does not return urine(gross hematuria in

almost al cases)

?

Delayed?

?

Fever

?

No urine output

?

Peritoneal signs

?

BUN / Creatinine

Bladder: Diagnosis: Hematuria

? Most (95%) have gross hematuria

? Microhematuria does occur: usually with

minimal injury


Indications of imaging

? Absolute

? Gross hematuria with pelvic fracture(30 % with

bladder rupture)

? Penetrating injury of lower abdomen with any

degree of hematuria

? Relative

? Gross hematuria without pelvic fracture
? Microscopic hematuria with pelvic fracture

Bladder: Diagnosis Plain Cystography

? Nearly 100% accurate

when done properly:

? Adequate filling with

350 cc

? Drainage films

? Use 30% contrast

? Underfilling (250 cc)

associated with false

negatives




Bladder: Diagnosis CT Cystography

? Preferred, especially if already getting other

CTs

? Antegrade filling by "clamping the Foley" is

not OK!

? Must dilute contrast (6:1 with saline, or to

about 2-4%)

Bladder: Diagnosis CT Cystography

Extraperitoneal

Intraperitoneal
Management (extraperitoneal bladder

rupture)

? Uncomplicated cases: conservative

management with catheter drainage.

? Large bore (22 fr ) should be used.
? Catheter removal 2 weeks after cystogram
? Complications reported with conservative

management (12% vs 5% with open repair)

like fistula ,clot retntion and sepsis.

Management (intraperitoneal bladder

rupture)

? All penetrating and intraperitoneal injuries

should be managed with immediate open

repair.

? Catheter removal 1 week after cystogram.


Ureteral Injury

? No reliable Physical findings! Usually a

retrograde diagnosis

? Non specific symptoms

? Flank pain (36%-90%)
? Fever
? Ileus
? Abdominal distension
? fistula


Etiology

? External trauma

? High speed blunt injuries

? Penetrating trauma

? Surgical injury

? Gynecological

? Obstetric

? General surgery( colorectal sx)

? Urologic procedures

? Ureteroscopic injury


Diagnosis

? Presense of hematuria(non specific)
? Imaging

? IVU
? CT urogram
? RGP
? Antegrade ureterography

? Intraoperative recognisation


Hematuria and ureteral injury

? Nonspecific indicator

? 25 ? 45% patients donot demonstrate even

microscopic hematuria.

? Being suspicious for it is the only way you will

catch it.


Management



Posterior Urethral Injuries

Posterior Urethra Trauma: Etiology

? 4-14% of pelvic fractures

? Bilateral pubic rami fractures (straddle

fracture) and sacroiliac diasthasis

? Mostly males, but can happen in females

? Associated bladder rupture in 10-17%

? Rectal injury can lead to urethral-rectal fistula

in 8%
Posterior Urethra Trauma: Diagnosis

? Blood at meatus: 50%

? Inability to urinate

? Palpable full bladder

? Inability to place urethral catheter

? High riding prostate : 34%

? Rarely, perineal hematoma (late finding)

? Rarely females develop proximal urethral

injury

? Presents with vulvar edema and blood at

vaginal introitus


Retrograde Urethrogram

Management

? Immediate open reconstruction(curently no

role)

? Suprapubic cystostomy
? Primary realignment
? Delayed reconstruction

? Endoscopic treatment
? Surgical reconstruction


Anterior urethral injury

? Are often isolated
? Majority after stradle injury
? Involve bulbar urethra
? Presents with blood at meatus,perenial

hematoma,gross hematuria n urinary

retention


Complications

? Erectile dysfunction

? 50%
? Cavernosal nerve injury
? Arterial insufficiency
? Venous leak
? Direct corporal injury

? Recurent stenosis(5-15%)
? Incontinence after reconstruction <4%

QUIZ (Grades of Renal Injuries)






Thanks