UROLOGIC TRAUMA

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UROLOGIC TRAUMA

• Hao Pan
• Department of Urology, the First Affiliated
  Hospital, College of Medicine, Zhejiang
  University

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UROLOGIC TRAUMA

• Renal Injuries
• Ureteral Injuries
• Bladder Injuries
• Urethral Injuries
• External Genitalia Injuries.

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• 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.

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Chapter 1Renal 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.

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Classification

• American Association for the Surgery of Trauma
  Organ Injury Severity Scale for the Kidney

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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.

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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• Excretory urography, which has largely been
  replaced by CT.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.

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• Grade I

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• Grade II

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• Grade III

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• Grade IV

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• Grade IV

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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.

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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.

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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.

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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.
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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.

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Chapter 2Ureteral 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.

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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.

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Classification

• American Association for the Surgery of Trauma
  Organ Injury Severity Scale for the Ureter

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Symptoms and signs

• 1. hematuria
• 2. Urinary extravasation
• 3. Obstruction, hydronephrosis
• 4. Urinary fistula.

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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.

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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.
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Computed tomography showing right medial
extravasation of contrast material in a patient
with a renal pelvis laceration.
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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.

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Chapter 3Bladder 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

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Diagnosis

• Retrograde cystography is the traditional imaging
  modality to diagnosis bladder rupture
• CT scan
• Bladder filling test.

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Plain film cystogram reveals extraperitoneal
bladder rupture with extravasation into scrotum.
Surgical exploration revealed anterior bladder
neck and prostatic urethral laceration
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CT cystogram demonstrates contrast material
surrounding loops of bowel consistent with
intraperitoneal bladder rupture.
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Management

• 1 Urethral catheter drainage, which is
  recommended in uncomplicated extraperitoneal
  bladder ruptures
• 2 Operative repair of the bladder.

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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
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Chapter 4Urethral Injuries

• Classification
• 1. anterior urethra (below the urogenital
  diaphragm)
• 2. posterior urethra (above the urogenital
  diaphragm).

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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.

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• In severe trauma, Buck's fascia may be disrupted,
  resulting in blood and urinary extravasation into
  the scrotum.

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Clinical signs

• 1 blood at the meatus
• 2 perineal hematoma,
• 3 gross hematuria,
• 4 urinary retention.

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Diagnosis of anterior urethral injuries

• 1 Patient history and physical examination
• 2 Diagnostic urethral catheterization,
• 3 X-Ray urethrography.

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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.

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Posterior urethral injuries

• Posterior urethral (above the
  urogenital diaphragm) injuries are often
  associated with many other pelvic injuries

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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.

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Diagnosis of posterior urethral injuries

• 1 Patient history and physical examination,
  
  AAADRE
• 2 X-Ray urethrography.

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Retrograde urethrogram in pelvic fracture patient
shows complete disruption of posterior urethra.
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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.

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Complication

• 1 Urethral stenosis
• 2 Impotence
• 3 Incontinence .

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Chapter 5 External Genitalia Injuries.

• Penile fracture usually occurs during sexual
  intercourse or masturbation, which sometimes
  associated with urethral injuries.
• Testicular rupture .

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Transverse laceration of right corpus cavernosum
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The End!