Traumatic Urological Emergencies

1. Traumatic Urological Emergencies Uğur Kaan Kalem Gr. V

2. TOPIC PAGE Introduction 3 Renal Trauma 7 Ureteral Trauma 24 Bladder Trauma 30 Urethral Trauma 44 Sources 57 Index

3. INTRODUCTION

4. Timely identification and management of blunt genitourinary injuries minimize associated morbidity, which may include impairment of urinary continence and sexual function.

5. Except in the rare instance of a shattered kidney or major renal vascular laceration, genitourinary injuries seldom pose a threat to life. • Once life-threatening conditions are stabilized, investigation for genitourinary injury is conducted in a retrograde fashion.

6. Common mechanisms of injury include motor vehicle collisions (MVC), falls from height, and direct blows to the torso or external genitalia. • Other important mechanisms include physical or sexual assault,and penetrating injuries. • As the genitourinary tract is seldom injured in isolation, a meticulous physical examination is crucial to avoid missing occult injuries.

7. RENAL TRAUMA

9. Renal trauma occurs in approximately 1-5% of all trauma cases. Renal injuries are associated with young age and male gender, and the incidence is about 4.9 per 100,000. • Most injuries can be managed conservatively. • Decreasedthe need for surgical intervention and increased organ preservation. Epidemiology & Etiology

10. Blunt Renal Injuries: • MVC • Falls from height • Vehicle-associated pedestrian accidents • Directblow to the flank or abdomen during sports activities • Assault Mechanism

11. In general, renal vascular injuries occur in less than 5% of blunt abdominal trauma, while isolated renal artery injury is very rare (0.05-0.08%)

12. Penetrating Renal Injuries: • Gunshot and stab wounds(most common cause) more severe and less predictable than blunt trauma. • Bullets have the potential for greatparenchymal destruction and are most often associated with multiple-organ injuries. • Penetrating injury produces direct tissue disruption of the parenchyma, vascular pedicles, or collecting system.

13. Gunshot Wound

14. AAST Renal Injury Grading Scale

16. Laboratory Evaluation • Urinalysis, hematocrit and baseline creatinine are the most important tests. • Hematuria, either non-visible or visible,is neither sensitive nor specific enough to differentiate between minor and major injuries.

17. Serial hematocrit determination is part of the continuous evaluation. A decrease in hematocrit and the requirement for blood transfusions are signs of blood loss. • A urine dipstick is an acceptable, reliable and rapid test to evaluate hematuria (false-negative results range from 3-10%)

18. Renalimaging should be undertaken in blunt trauma if there is macroscopic hematuria or microscopic hematuria and hypotension(SBP< 90 mmHg) • In patients with penetrating trauma, with the suspicion of renal injury, imaging is indicated regardless of hematuria. Radiographic Assessment

19. Ultrasonography (US) • Intravenous pyelography (IVP) • Intraoperative pyelography • Computed tomography (CT) • Magnetic resonance imaging (MRI)

20. Management

23. Bleeding • Infection • Perinephric abscess • Sepsis • Urinary Fistula • Hypertension • Chronic Pyelonephritis • Calculus Formation • AV fistula • Hydronephrosis Complications

24. URETERAL TRAUMA

26. Ureteraltrauma accounts for 1-2.5% of urinary tract trauma. • Greater incidence of penetratingexternal ureteral trauma (mainly gunshot wounds) • 1/3 of cases by blunt trauma (mainly by MVC) • Iatrogenic (Esp. Gynecological approaches) Epidemiology & Etiology

27. Diagnosis is challenging Delayed Diagnosis • Flank pain • Urinary incontinence • Urinary leakage • Haematuria • Fever

28. Extravasation of contrast medium on CT is the hallmark sign of ureteral trauma. • Retrogradeor AntegradeUrographyis the gold standard for confirmation Radiographic Assessment

29. Management

30. BLADDER TRAUMA

31. Etiology

32. Incidence of iatrogenic bladder trauma

33. Cardinal sign is visible hematuria. Diagnostic Evaluation

34. Cystography • Cystoscopy • US Imaging

35. Cystography: • Cystography is the preferred diagnostic modality for non-iatrogenic bladder injury and for a suspected iatrogenic bladder trauma. • Both plain and CT cystography have a comparable sensitivity (90-95%) and specificity (100%)

39. Conservative Management • Clinicalobservation, continuous bladder drainage and antibiotic prophylaxis Surgical Management • Blunt non-iatrogenic trauma • Penetrating non-iatrogenic trauma • Iatrogenic trauma • Foreign body Management

40. Blunt non-iatrogenic trauma • Non-complicated extraperitoneal ruptures can be treated conservatively. • Other organ/tissue involvments with ext. Peritoneal ruptures may need surgical intervention.

41. Blunt non-iatrogenic trauma • Intraperitoneal ruptures are always managed by surgical repair. Otherwise, intraperitonealurine extravasation can lead to: • Peritonitis • Intra-abdominal sepsis • Death

42. Penetrating non-iatrogenic trauma • The standard treatment is emergency exploration, debridement, and primary bladder repair.

43. Iatrogenic trauma Perforations recognised intra-operatively are primarily closed. Intraperitoneal Extraperitoneal

44. URETHRAL TRAUMA

46. The most common type of urethral trauma seen in urological practice is iatrogenic, due to catheterisation, instrumentation, or surgery. • Iatrogenic urethral trauma usually results from improper or prolonged catheterisation and accounts for 32% of strictures. • The size and type of catheter used have an important impact on urethral stricture formation.  Etiology

49. Transurethral procedures are a common cause of iatrogenic urethral trauma. • In the presence of urethral disruption, a suprapubic catheter should be placed.