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UROLOGIC TRAUMA. Hao Pan Department of Urology, the First Affiliated Hospital, College of Medicine, Zhejiang University. UROLOGIC TRAUMA:. Renal Injuries; Ureteral Injuries ; Bladder Injuries; Urethral Injuries ; External Genitalia Injuries.
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UROLOGIC TRAUMA Hao Pan Department of Urology, the First Affiliated Hospital, College of Medicine, Zhejiang University
UROLOGIC TRAUMA: • Renal Injuries; • Ureteral Injuries; • Bladder Injuries; • Urethral Injuries; • External Genitalia Injuries.
Of all injuries to the genitourinary system, urethral and renal Injuries are common. • Usually associated with other organs or tissues injuries. • Hematuria is the best indicator of traumatic injury to the urinary system.
Chapter 1:Renal Trauma (etiology) • Blunt renal injuries most often come from motor vehicle accidents, falls from heights, and assaults; • Penetrating renal injuries most often come from gunshot and stab wounds; • Iatrogenic. • Renal tumor.
Classification: American Association for the Surgery of Trauma Organ Injury Severity Scale for the Kidney
Symptoms and signs: 1. shock; 2. hematuria: microscopic or gross hematuria. however, the degree of hematuria and the severity of the renal injury do not correlate consistently; 3. pain; 4. fever, due to secondary infection.
Diagnosis • Patient history and physical examination; • Urinalysis, hemoglobin; • Ultrasound, immediate evaluation of injuries; • Computed tomography (CT) with contrast enhanced (preferred imaging study ); • Excretory urography, which has largely been replaced by CT. • Arteriography.
Management: • Nonoperative Management, Most renal injuries are Grade I, can be managed nonoperatively. 1, hospital admission and bed rest for 2-4 weeks; 2, vital sign monitoring; 3, transfusion; 4, antibiotics; 5, close clinical follow-up.
Management: • Operative Management , 1, Absolute indications: Persistent renal bleeding, expanding perirenal hematoma, pulsatile perirenal hematoma. 2, Relative indications: Urinary extravasation, nonviable tissue, delayed diagnosis of arterial injury, segmental arterial injury, other organ injuries and incomplete staging.
Management: • Operative Management , Renal Exploration: Transabdominal approach is recommended for early exploration of the renal hilum and vasculature to stop the bleeding. reconstructive surgery or nephrectomy.
The surgical approach to the renal vessels and kidney: A, retroperitoneal incision over the aorta medial to the inferior mesenteric vein; B, anatomic relationships of the renal vessels; C, retroperitoneal incision lateral to the colon, exposing the kidney.
Complications 1.Urinoma, perinephric infection, sometimes perinephric abscess and renal loss, which usually followed persistent urinary extravasation. 2. Delayed renal bleeding. 3. Hypertension, (1) renal vascular injury, leading to stenosis or occlusion of the main renal artery or one of its branches; (2) compression of the renal parenchyma with extravasated blood or urine; (3) post-trauma arteriovenous fistula. In these instances, the renin-angiotensin axis is stimulated by partial renal ischemia, resulting in hypertension.
Chapter 2:Ureteral Injuries • Ureteral injuries after external violence are rare and can be missed because patients often do not exhibit hematuria. Associated visceral injury is common, • Diagnosis: delayed CT contrast images.
Chapter 2: Iatrogenic Ureteral Injuries • Surgical Injury, largely result from surgeries in the pelvis (such as hysterectomy) and retroperitoneum. Intimate knowledge of its location is important. • Ureteroscopic Injury; • Radiation.
Classification: American Association for the Surgery of Trauma Organ Injury Severity Scale for the Ureter
Symptoms and signs: 1. hematuria; 2. Urinary extravasation; 3. Obstruction, hydronephrosis; 4. Urinary fistula.
Diagnosis • Patient history and physical examination; • Excretory urography, However, IVP findings are often subtle and nonspecific. • Computed tomography (CT): extravasation of contrast material. • Retrograde Ureterography (recommended). simultaneous placement of a ureteral stent. • Methylene Blue injection intraoperatively.
Excretory urography demonstrating extravasation in the upper right ureter consequent to stab wound. Note lack of contrast (arrow) in the ureter below the site of injury, indicating complete ureteral transection.
Computed tomography showing right medial extravasation of contrast material in a patient with a renal pelvis laceration.
Management: 1. Placement of a ureteral stent; 2. Ureteroureterostomy, or so-called end-to-end repair, is used in injuries to the upper two thirds of the ureter; 3. Transureteroureterostomy; 4. Ureteroneocystostomy. 5. Autotransplantation of the kidney; 6. Transposition of bowel to replace the ureter; 7. Nephrectomy.
Chapter 3:Bladder Injuries Bladder injury after blunt trauma is relatively rare owing to the protected intrapelvic position of the bladder. Sometime bladder rupture associated with pelvic fracture. • 1 extraperitoneal • 2 intraperitoneal
Diagnosis • Retrograde cystography is the traditional imaging modality to diagnosis bladder rupture; • CT scan; • Bladder filling test.
Plain film cystogram reveals extraperitoneal bladder rupture with extravasation into scrotum. Surgical exploration revealed anterior bladder neck and prostatic urethral laceration
CT cystogram demonstrates contrast material surrounding loops of bowel consistent with intraperitoneal bladder rupture.
Management: • 1 Urethral catheter drainage, which is recommended in uncomplicated extraperitoneal bladder ruptures; • 2 Operative repair of the bladder.
A, Dense flame-shaped pattern of contrast agent extravasation in pelvis due to extraperitoneal bladder rupture. B, Repeated cystogram in same patient after 2 weeks of catheter drainage shows completely healed bladder
Chapter 4:Urethral Injuries Classification: 1. anterior urethra (below the urogenital diaphragm); 2. posterior urethra (above the urogenital diaphragm).
Anterior urethral injuries Anterior urethral (below the urogenital diaphragm) injuries are often associated with straddle injuries, which are most often isolated . The bulbar urethra is typically the site of injury. Anterior urethral injuries are divided as following: contusion, incomplete disruption, and complete disruption.
In severe trauma, Buck's fascia may be disrupted, resulting in blood and urinary extravasation into the scrotum.
Clinical signs: • 1 blood at the meatus • 2 perineal hematoma, • 3 gross hematuria, • 4 urinary retention.
Diagnosis of anterior urethral injuries : • 1 Patient history and physical examination; • 2 Diagnostic urethral catheterization, • 3 X-Ray: urethrography.
Management of anterior urethral injuries: • 1. Urethral catheter diversion alone; • 2. Anastomotic urethroplasty; • 3. In cases of severe anterior urethral injury, suprapubic cystostomy may be required, followed by delayed open surgical repair.
Posterior urethral injuries Posterior urethral (above the urogenital diaphragm) injuries are often associated with many other pelvic injuries;
Clinical signs: • 1 presence of blood at the urethral meatus; • 2 inability to urinate, • 3 palpably full bladder. • 4 pain • 5 shock • Urethral disruption is often first detected when a urethral catheter cannot be placed or misplaced into pelvic hematoma.
Diagnosis of posterior urethral injuries : • 1 Patient history and physical examination, AAADRE; • 2 X-Ray: urethrography.
Retrograde urethrogram in pelvic fracture patient shows complete disruption of posterior urethra.
Management of Posterior urethral injuries : • Suprapubic Cystostomy, which is followed by delayed combined antegrade and retrograde endoscopic repair or open surgical repair, • Primary Realignment, which is reasonable in stable patients. When the urethral catheter is removed after 4 to 6 weeks, it is imperative to retain a suprapubic catheter because most patients will, despite realignment, develop posterior urethral stenosis.
Complication: • 1 Urethral stenosis; • 2 Impotence; • 3 Incontinence .
Chapter 5: External Genitalia Injuries. • Penile “fracture” usually occurs during sexual intercourse or masturbation, which sometimes associated with urethral injuries. • Testicular rupture .
