TRAUMA UROGENITAL

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TRAUMA UROGENITAL

• Anatomi
• Ginjal
• Ureter
• Buli buli
• Uretra

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TRAUMA UROGENITAL

• Anatomi
• Ginjal
• Ureter
• Buli buli
• Uretra

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Ginjal

• Sepasang organ seperti kacang
• Terletak retroperitonel diregio lumbal superior
• Dilapisi oleh 3 lapis jaringan penunjang
• kapsul ginjal
• kapsul adipose dan
• fasia renalis

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Ureter

• Tubulus muscular yang menghubungkan ginjal ke
  buli buli
• Terletak di belakang rongga peritoneum
  (retroperitoneal)
• Panjang 25 30 cm

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TRAUMA GINJAL

• Trauma Ginjal
• Sering
• 8-10 trauma tumpul / tajam abdomen
• Separuh dari kejadian trauma urogenital
• Di proteksi
• Otot-otot lumbal
• Iga
• Vertebrae

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Angka kesakitan / kematian ok trauma ginjal
tergantung

• Derajat trauma
• Keterlibatan trauma organ lain
• Fasilitas penanggulangan trauma

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Buli-buli

• Buli buli normal dapat menampung 350 450 mL
  urine
• Drainase kendung kemih bermuara ke vena iliaca
  interna

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Uretra

• Tabung yang menyalurkan urine ke luar dari
  buli-buli
• Secara anatomis uretra dibagi menjadi 2 bagian
• Uretra posterior dan
• Uretra anterior

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Mekanisme Trauma

• Trauma tumpul -gt penyebab trauma
• Langsung, tidak langsung
• Trauma tumpul langsung
• KLL
• Olah raga
• Kecelakaan kerja
• Perkelahian

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• Trauma tumpul tidak langsung
• Jatuh dari ketinggian
• KLL
• ? menyebabkan pergerakan ginjal
• tiba-tiba dlm rongga retro peritonium ?
  Avulsi pedikel ginjal
• Robekan tunika intima

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• Bisa juga oleh trauma iatrogenik
• Pemasangan kateter di atas ureter
• Pengambilan biopsi ginjal
• Infeksi tidak langsung
• Klasifikasi
• Ada beberapa macam
• Ditentukan oleh luas dan penatalaksanaan

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• Cedera Ginjal
• Minor
• Mayor
• Vaskuler
• Cedera Minor
• 90 trauma ginjal
• Kontusio ginjal
• Laserasi parenkim superficial

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• Cedera Mayor
• Laserasi korteks, medula tanpa ekstravasasi
• Laserasi korteks, medula dengan ekstravasasi
• Cedera Vaskuler
• Avulsi
• Trombosis

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Berdasarkan AAST ( American for The Surgery of
Trauma )
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Berdasarkan AAST( American for The Surgery of
Trauma )

• Dibagi 5 derajat
• Derajat 1
• Kontusio ginjal /subkapsularhematom
• Tidak meluas
• Hematuria dengan normal imaging

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• Derajat 2
• Hematom perineal
• Tdk meluas ke retroperitonium
• Laserasi superficial ( lt 1cm )
• Tdk melibatkan collecting systim
• Derajat 3
• Renal laserasi ( gt 2cm )
• Sub capsular hematom
• Perinephric hematom
• Tdk melibatkan collecting systim

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• Derajat 4
• Laserasi yang meluas ke collecting systim
• Extravasasi
• Trauma vasculer ? segmental infark

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• Derajat 5
• Shattered kidney
• Devaskularisasi / oklusi / trombosis
• arteri / vena utama
• Laserasi komplit
• Extravasasi
• UPJ avulsi

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Pemeriksaan Radiologi

• Foto polos abdomen
• IVP ( Intra Vena Pyelografi )
• USG ( Ultra Sonographi )
• CT Scan abdomen / Whole abdomen
• uretrocistografi

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IVP Melihat ekstravasasi urin / kontras
Tidak bisa mendeteksi trauma ginjal derajat I,
II Fungsi ginjal kontra lateralUSG Melihat
hemoperitoneum Tdk dianjurkan utk evaluasi
trauma ginjal Dengan color doppler ?
melihat vaskuler
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• CT Scan
• Pemeriksaan yang sensitif dan spesifik
• Menentukan derajat trauma
• Tidak invasif
• Dpt mengevaluasi organ lain
• ( hepar , lien , aorta )
• kontras non kontras
• Angiografi
• Invasif
• Delayed renal bleeding-pseudo-aneurisma

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• IVP normal

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USG ginjal normal
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• CT scan ginjal normal

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Gambar 1. Kidney trauma. Absent nephrogram.
Abdominal radiograph after intravenous contrast
administration in a patient with hypotension
after a motor vehicle collision shows absent
right nephrogram
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Gambar 2. Kidney trauma. Grade 3 renal laceration
on abdominal radiograph. Abdominal radiograph
after intravenous contrast administration shows
very diminished left nephrogram and no urinary
contrast extravasation
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Gambar 3. Kidney trauma. Grade 5 renal injury.
Shattered kidney with renal vein thrombosis
(incomplete). Abdominal radiograph after
intravenous contrast administration shows absent
right nephrogram
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Gambar 4 Kidney trauma. Grade 1 renal injury,
contusion. Image from a contrast-enhanced CT scan
of the abdomen in a patient with hematuria after
a motor vehicle collision shows ill-defined area
of hypoenhancement in the medial right kidney.
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Gambar. 5. Kidney trauma. Grade 1 renal injury,
subcapsular hematoma. CT scan of the abdomen with
intravenous contrast in a patient after a motor
vehicle collision shows crescentic high-density
fluid collection around the left kidney. Note the
well-defined outer margin
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Gambar 6. Kidney trauma. Grade 1 renal injury,
subcapsular hematoma. CT scan of the abdomen with
intravenous contrast in a patient after a motor
vehicle collision shows crescentic high-density
fluid collection around the left kidney. Note the
well-defined outer margin and the mild deformity
of the renal parenchyma
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Derajat II dan III
Gambar 6. Kidney trauma. Grade 2 renal injury,
subcapsular and perinephric hematomas.
Contrast-enhanced CT scan of the abdomen on a
patient with hematuria after a motor vehicle
collision shows an ill-defined fluid collection
in the left perinephric space. There is also a
subcapsular hematoma with deformity of the renal
parenchyma
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Gambar 7 Kidney trauma. Grade 2 renal injury,
perinephric hematoma. Contrast-enhanced CT scan
of the abdomen on a patient with hematuria after
a motor vehicle collision shows an ill-defined
fluid collection in the left perinephric space
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Gambar 8. Kidney trauma. Grade 3 renal laceration
with normal one-shot intravenous pyelogram. CT
scan through the kidneys after intravenous
contrast on the same patient as in Image 1 shows
renal laceration and perinephric hematoma.
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Gambar 9 Kidney trauma. Grade 2 renal laceration.
Contrast-enhanced CT scan of the abdomen after a
motor vehicle collision shows a superficial (less
than 1 cm deep) renal parenchymal defect with a
large perinephric hematoma
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Gambar 10. Kidney trauma. Grade 2 renal
laceration. Delayed image shows no urinary
contrast extravasation. Contrast-enhanced CT scan
of the abdomen after a motor vehicle collision
shows a superficial (lt1 cm deep) renal
parenchymal defect with a large perinephric
hematoma
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Gambar 11. Kidney trauma. Grade 3 renal
laceration. CT scan of the abdomen after
intravenous contrast administration shows
irregular nonenhancing renal parenchymal defect
with extension greater than 1 cm deep to near the
renal pelvis. no urinary contrast extravasation
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Gambar 12. Kidney trauma. Grade 3 renal
laceration. CT scan of the abdomen after
intravenous contrast administration shows
irregular nonenhancing renal parenchymal defect
with extension greater than 1 cm deep to near the
renal pelvis. This delayed image showed no
urinary contrast extravasation.
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• Derajat IV

Gambar13 Kidney trauma. Grade 4-5 renal injury.
Lacerations extending to the collecting system.
Contrast-enhanced CT scan of the abdomen in a
patient with hematuria after a motor vehicle
collision shows deep lacerations extending into
the collecting system of the right kidney.
Extension into the collecting system is confirmed
by urinary contrast extravasation on delayed
image through the kidney in excretory phase
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Gamba14. Kidney trauma. Grade 4-5 renal injury.
Lacerations extending to the collecting system.
Contrast-enhanced CT scan of the abdomen in a
patient with hematuria after a motor vehicle
collision shows deep lacerations extending into
the collecting system of the right kidney (Image
22). Extension into the collecting system is
confirmed by urinary contrast extravasation on
this delayed image through the kidney in
excretory phase
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Gambar 15. Kidney trauma. Grade 4 renal injury
segmental infarction. Contrast-enhanced CT scan
of the upper abdomen shows a segmental area of
nonenhancement in the upper medial left kidney
without associated renal laceration
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Gambar 16. Kidney trauma. Grade 4 renal injury
segmental infarction. Contrast-enhanced CT scan
of the upper abdomen in another patient after a
motor vehicle collision shows a segmental area of
nonenhancement in the upper medial left kidney
without associated renal laceration
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• Derajat V

Gambar 17. Kidney trauma. Grade 5 renal injury.
Shattered kidney. Contrast-enhanced CT scan of
the abdomen in a patient with hematuria and
hypotension after a motor vehicle collision shows
transection of the right kidney with a large
hematoma around and between the 2 halves of the
kidney. The 2 halves are both perfused because
there were 2 renal arteries Delayed images show
urinary contrast extravasation
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Gambar 18. Kidney trauma. Grade 5 renal injury.
Shattered kidney. Contrast-enhanced CT scan of
the abdomen in a patient with hematuria and
hypotension after a motor vehicle collision shows
transection of the right kidney with a large
hematoma around and between the 2 halves of the
kidney. The 2 halves are both perfused because
there were 2 renal arteries. Delayed images show
urinary contrast extravasation
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Gambar 19 Kidney trauma. Grade 5 renal injury.
Shattered kidney. Contrast-enhanced CT scan of
the abdomen in a patient with hematuria and
hypotension after a motor vehicle collision shows
transection of the right kidney with a large
hematoma around and between the 2 halves of the
kidney. The 2 halves are both perfused because
there were 2 renal arteries Delayed images show
urinary contrast extravasation
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Gambar 20. Kidney trauma. Grade 5 renal injury.
Shattered kidney. Contrast-enhanced CT scan of
the abdomen in a patient with hematuria and
hypotension after a motor vehicle collision shows
transection of the right kidney with a large
hematoma around and between the 2 halves of the
kidney. The 2 halves are both perfused because
there were 2 renal arteries. Delayed images show
urinary contrast extravasation
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Gambar 21. Kidney trauma. Grade 5 renal injury.
Shattered kidney with renal vein thrombosis
(incomplete). CT scan of the abdomen with
intravenous contrast administration shattered
right kidney and renal vein thrombus extending
slightly into the inferior vena cava
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Gambar 22. Kidney trauma. Normal ultrasound with
grade 5 renal injury. Ultrasound gray-scale image
of a patient involved in a motor vehicle
collision shows what appears to be a normal right
kidney
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Gambar 23 Kidney trauma. Grade 5 renal injury.
Color Doppler ultrasound of same motor vehicle
collision patient as in Image 4 shows no blood
flow within the right kidney.
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• 4.Arteriografy

Gambar 24. Kidney trauma. Active vascular
contrast extravasation. Catheter angiography
during arterial phase on the same patient as in
Image 40 shows a small pseudoaneurysm at the
lower pole
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gambar 25. Kidney trauma. Active vascular
contrast extravasation. Catheter angiography
during nephrographic phase in the same patient as
in Image 41 shows a small pseudoaneurysm at the
lower pole
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gambar 26. Kidney trauma. Active vascular
contrast extravasation. Pseudoaneurysm at the
lower pole in the same patient as in Image 42 was
embolized by using a coil.
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Trauma Ureter

• Ureter ? jalur transportasi dari ginjal ke
  buli-buli
• Trauma ureter ? mengganggu fungsi ginjal
• Trauma mengenai pinggang, punggung ?
• resiko mengenai ureter
• ok Lokasi terlindungi
• Ukuran kecil
• Mobilitas / fleksibel
• ??? trauma ureter ? jarang

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• Etiologi
• Trauma Luar
• a. Tajam
• b. Tumpul
• Iatrogenik ?
• a. Ginekologis
• b. Pembedahan rektum
• c. Endoskopi

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Pemeriksaan Radiologi

• IVP ( Intra Vena Pyelografi )
• RPG ( Retro Grade Pyelografi )
• USG ( Ultra Sono Grafi )
• CT Scan Abdomen

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Trauma Vesika Urinaria

• Disebabkan Trauma
• - Tumpul
• - Tajam
• - Iatrogenik
• Didaerah pelvis / abdomen bawah/
• perineum
• 60-85 ? trauma tumpul
• 15-40 ? trauma tajam

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• Ruptur vesika urinaria ke
• Ekstra peritoneum
• Intra peritoneum
• Keduanya
• Kontusio Vesika Urinaria
• Sobekan sebagian mkosa vesika urinaria
• Dinding ? memar ? hematom
• Pemeriksaan
• Sistografi
• CT scan abdomen - pelvis

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• Kontusio Vesika Urinaria
• Normal
• Tear Drop
• Mudah sembuh
• Ruptur Vesika Urinaria
• Terlihat ekstravasasi kontras
• - ekstra peritonial
• - intra peritonial
• Dengan CT Scan ? dpt juga mengevaluasi organ lain

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Pear shaped appearance
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TRAUMA URETRA

• Uretra laki-laki lebih panjang dari wanita
• Dihubungkan dgn trauma daerah pelvis yg cukup
  berat
• Etiologi
• Trauma tumpul
• Trauma tembus
• Iatrogenik

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• Anatomi
• Uretra posterior ?
• uretra prostatika
• uretra membranosa
• Uretra anterior ?
• 3 segmen pars bulosa
• pars pendulans
• pars glanularis
• sampai ke meatus uretra externa

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• Diagnosa
• Berdasarkan gejala klinik
• Pemeriksaan penunjang ? radiologi?
• RUG ( Retrograde Uretrografi )
• Klasifikasi trauma uretra ? Hasil RUG
• Klasifikasi ? Gold Man yaitu
• Berdasarkan Kerusakan Anatomi

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• Ada 5 tipe
• Tipe 1
• . Ruptur ligamentum puboprostatika
• . Prostate bergeser ke posterior
• . Uretra tetap intak
• . Tdk ada extra vasasi zat kontras

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• Tipe 2
• Trauma uretra posterior diafragma
• urogenital
• Terlihat extravasasi kontras dlm pelvis extra
  peritoneal
• Zat kontras tdk ada dalam perineum

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• Tipe 3
• Tipe yang sering
• Kerusakan meluas
• Terlihat extravasasi kontras pada rongga pelvis
  extra peritoneal dan perineum

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• Tipe 4
• Terjadi dekat buli-buli meluas ke uretra proximal
• Extravasasi kontras pada pelvis extra peritoneal
  sekitar proximal uretra
• Dapat merusak sfingter uretra interna

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• Tipe 5
• Terjadi di uretra anterior
• Terlihat extravasasi kontras bagian inferior
  diafragma urogenital

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TERIMA KASIH