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Urology

Trauma

Urology

Urology|Trauma
by Alegro, Orbino, Ranario, Relatorres

Urology
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Trauma

Trauma

Trauma

OUTLINE OF TOPICS
I. Infections II. Malignancies

III.Trauma
IV. Emergencies V. Lower Urinary Tract Obstruction
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You still remember this, right?

Kidneys Ureters Urinary bladder Urethra

KIDNEY
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Fact s
Approximately 10% of traumas involve the urologic system, most commonly the kidneys (9th ed. Schwartz). Renal injuries are more common during blunt trauma, accounting for 90% of injuries to the kidney (8th ed. Schwartz). The best study for evaluating the kidneys is a helical abdominal CT scan with IV contrast. A CT scan should be performed for all penetrating traumas.

Who should undergo Radiographic Imaging of the Kidneys?

Adult and Pediatric patients with major deceleration injury, shock, gross or microscopic hematuria and systolic blood pressure less than 90 mm Hg at any point during the transport and resuscitation. All patients with penetrating injuries to the flank or abdomen and lower rib fractures, (exception) if unstable and requiring immediate exploration.

*From Schwartz 8th and 9th Ed.

Blunt Renal Trauma

(Bicycle Accident)

A.) Left Kidney, w/ several deep lacerations in the collecting system. B.) CT image @ 45 days Large significant showing perirenal hematoma. improvement in the appearance of the kidney

Classification of Trauma

d staging system for renal injury was developed by the American Associatio

Classification of Trauma
Renal injuries are classified by extent of damage .
Approximately 95% of renal traumas are grade 1.

Approximately 98% of renal injuries can be managed nonoperatively.

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Indications
The only absolute indications for surgical management of a renal injury are persistent bleeding resulting in hemodynamic instability or an expanding perirenal hematoma. Relative indications for surgical management include major urinary extravasation, vascular injury, and devitalized parenchymal tissue.

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Indications

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 Studies show that even large urinary extravasations will resolve with conservative management. Smaller vascular injuries resulting in devitalized tissue also can be managed without surgery; however, if the amount of devitalized tissue exceeds 20% of the renal tissue, surgical management leads to quicker resolution of the injury and to fewer subsequent complications.

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When do we manage conservatively?

Blunt traumatic injuries - Managed conservatively Urinary extravasation - does not require exploration, but reimaging is necessary and, if persistent leakage is present, a stent or nephrostomy tube is indicated. High-grade renal injuries are associated with significant bleeding, but patients who are stable and without a pulsatile or expanding hematoma can be observed. Most grade IV injuries can be managed nonoperatively. Patients typically are placed on restricted activity until hematuria resolves.

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When do we do exploration?
Penetrating renal injuries Exploration All Grade V vascular injuries should be considered for immediate exploration, a delay of several hours greatly decreases the risk of renal salvage. If the IVP is abnormal or the hematoma is pulsatile. When the renal hilum is controlled.

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Remember!
Surgical exploration should be performed through a midline approach. The renal vessels should be identified and controlled prior to opening Gerota's fascia, in order to allow the vessels to be rapidly occluded if massive bleeding is encountered. Injuries to the collecting system should be repaired by a watertight closure. Devitalized tissue should be excised and meticulous hemostasis should be obtained by ligating open segmental vessels.

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Remember!
If immediate operative exploration for other injuries is required, renal injury staging can be performed while in the operating room. If concern exists over renal injury or the presence of a retroperitoneal hematoma, a single-shot, 10-minute delayed IV pyelogram (IVP) (2 mL/kg contrast) is useful at assessing the presence of two functional kidneys and extent of injury. Although rarely necessary, temporary control of the renal hilum may decrease the need for nephrectomy when a significant injury is found on exploration. Complete exposure is necessary to evaluate the extent of injury.
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Remember!
All nonviable tissue should be dbrided and segmental and intralobar arteries ligated with 4-0 chromic or polydioxanone sutures. If the collecting system is injured, it should be repaired immediately A stent and percutaneous drain should be considered to prevent urinoma formation. A partial vascular injury to the renal vein or artery can be repaired with 5-0 or 6-0 Prolene sutures. A complete injury may require dbridement, and if an end-to-end anastomosis cannot be performed, a vascular graft may be required.

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URETER
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URETER

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 The retroperitoneal location of the ureter protects it from external trauma, and blunt injury is rare but can occur with rapid deceleration injuries. The ureter also is frequently injured intraoperatively, most commonly from open and laparoscopic surgical procedures including hysterectomy, low-anterior colonic resections, or aortic surgery. Any penetrating trauma involving the retroperitoneum should undergo evaluation with

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Epidemiology Ureter is involved <1% of all GU injuries caused by external trauma The total incidence of ureteral injury after gynecologic surgery is reported at 0.5 1.5%, and after abdominoperineal colon resection it ranges from 0.3 5.7%. The reported rate of ureteral injury during laparoscopic surgery varies between 0.5% (experienced surgeons) and 14%

Symptoms and signs of Ureteric injury:

Fever Haematuria Flank pain Abdominal distension Abscess formation/sepsis Peritonitis/ileus Retroperitoneal urinoma Postoperative anuria Urinary leakage (vaginally or via abdominal wound) Secondary 22 hypertension

 Surgical repair depends on location and extent of injury

a)Partial injuries
can be primarily repaired, although all devitalized tissue must be dbrided to avoid delayed tissue breakdown and urinoma formation. Ureteral stents should be placed in this situation to facilitate healing without stricture. The main complications with ureteral stents are dislocation,infection and blockage by encrustation. Recently stents with coatings, such asheparin , were approved to reduce

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b.) Lower ureteral injuries(below the iliac vessels) are best treated with ureteral reimplant, as the blood supply can be tenuous, and strictures are more common with a distal uretero

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c.) Midureteral level injuries can be treated with a ureteroureterostomy if a spatulated, tension-free repair can be achieved.

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 For longer defects, the bladder can be mobilized and brought up to the psoas muscle (psoas hitch).

For additional length, a tubularized flap of bladder (Boari flap) can be created and anastomosed to the remaining ureter. Renal mobilization with nephropexy by anchoring to the psoas muscle can provide additional length.

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Bladder
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 Bladder injury can occur from penetrating and blunt trauma. Bladder injuries often are associated with pelvic fractures and may frequently occur in conjunction with urethral injuries. A delayed presentation can be associated with intoxication, but it also may occur as a result of iatrogenic injury Radiographic evaluation 28

Epidemiology Blunt trauma with bladder injury is associated with pelvic fracture in more than 95% of cases. Intraoperative bladder injuries account for: a. Laparoscopic injuries (0.28.3%) b.Intraperitoneal (38 40%) c. Extraperitoneal (54 56%) of injuries d.Laparoscopic injuries diagnosed: 53.2% intraoperatively

Symptoms and signs of Bladder injury :

suprapubic pain Dysuria/ Anuria/ Hematuria Anorexia, lethargy Progressive dehydration. Abdominal distension. Fever.

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Types of injury management:

a)Extraperitoneal bladder injuries

can typically be managed with catheter drainage for 7 to 10 days drainage if urine is draining freely and the bladder neck is spared. If the bladder neck is involved, surgical exploration and repair are required.

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a)Intraperitoneal bladder injuries

should be explored immediately and repaired.

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 All injuries, especially those managed nonoperatively, should be followed up by a cystogram to document healing before catheter removal.

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URETHRA
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 Urethral injuries can be classified into 2 broad categories based on the anatomical site of the trauma: 1.Posterior urethral injuries - located in the membranous and prostatic urethra - these injuries are most commonly related to major blunt trauma such as motor vehicle collisions and major falls, and most of such cases are accompanied by pelvic fractures

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2. Anterior urethral injuries - located distal to the membranous urethra - most anterior urethral injuries are caused

by blunt trauma to the perineum (straddle injuries), and many have delayed manifestation, appearing years later as a urethral stricture

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 External penetrating trauma to the urethra is rare, but iatrogenic injuries are quite common in both segments of the urethra. Most are related to difficult urethral catheterizations.

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Posterior urethra ( 5 cm ) prostatic ( 3 - 4 cm ) membranous ( 1 - 2 cm )

Anterior urethra bulbar ( 7 penile ( 6 navicular

( 15 cm ) cm ) cm ) ( 2 cm )

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ETIOLOGY

As with many traumatic events, the etiology of a urethral injury can be classified: 1. blunt 2. penetrating

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Blunt Injuries
1. Posterior Urethra - almost always related to massive deceleration events such as falls from some distance or vehicular collisions - these patients most often have a pelvic fracture involving the anterior pelvis

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Blunt Injuries
2. Anterior Urethra - most often results from a blow to the bulbar segment such as occurs when straddling an object or from direct strikes or kicks to the perineum - blunt anterior urethral trauma is sometimes observed in the penile urethra in the setting of penile fracture

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Penetrating trauma

- most often occurs to the penile urethra - etiologies include gunshot and stab wounds

Iatrogenic injuries to the urethra occur when difficult urethral catheterization leads to mucosal injury with subsequent scarring and stricture formation. Transurethral procedures such as prostate and tumor resections and ureteroscopy can also lead to urethral injury.
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SYMPTOMS and SIGNS

- pain with voiding and inability to void - perineal, scrotal, and penile ecchymosis, edema, or both - a high-riding prostate on rectal examination

Blood at the urethral meatus is the most important sign of a urethral injury.
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WORKUP
Imaging Studies Retrograde urethrography: The retrograde urethrography is the standard imaging study for the diagnosis of urethral injury. It is performed using gentle injection of 20-30 mL of contrast into the urethra. Examination is made for extravasation, which pinpoints the existence and location of the urethral tear. Cystography: The static cystography allows for concurrent bladder injury to be excluded in the acute setting. When a delayed repair is being considered, voiding cystography (performed through the suprapubic catheter) demonstrates the bladder neck and prostatic urethral anatomy and allows for proper surgical planning.
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Urethra, trauma. Normal retrograde urethrogram. Pericatheter retrograde urethrogram is negative for urethral trauma and shows continuous filling of contrast material through the extent of the urethra and into the bladder without extravasation.

Urethra, trauma. Retrograde urethrogram reveals a tight stricture, a common morbidity of urethral injuries treated with delayed repair.

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Urethra, trauma. Cystogram reveals stricture of the urethra in a patient treated with delayed repair (same patient as in the previous image). The cystogram and retrograde urethrogram together help define the length of the stricture.
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TREATMENT
Contusions can be safely treated with 10 days of indwelling transurethral catheterization. Partial disruptions are best treated with bladder drainage via suprapubic cystostomy. In selected cases of posterior partial disruptions, primary urethral realignment using catheterization may be attempted; if successful, this approach limits subsequent urethral strictures.

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TREATMENT
Complete disruptions are treated with bladder drainage via suprapubic cystostomy. This option is simplest and can be used safely in all patients. Definitive surgery is deferred for about 8 to 12 wk until the urethral scar tissue has stabilized and the patient has recovered from any accompanying injuries. Selected penetrating urethral injuries and blunt urethral injuries that occur with penile fractures may be sutured primarily.

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TESTES
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TESTES
Testicular injury blunt injuries (common) Ultrasound
testicular blood flow testicular contusions Intratesticular hematomas Hematoceles disrupted tunica albuginea.

Goal of surgery
To avoid delayed complications
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A geh!

Hala sorry!

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...last but not the least

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PENIS
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Read

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PENIS

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Rare injuries butterfly sign exploration Retrograde urethrogram

A.) Patient with a penile fracture.

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B.) Intra-operative finding of bilateral corporal body ruptures (arrows) along the ventral penile surface.

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The End

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