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
This post was last modified on 08 April 2022