GENITOURINARY TRAUMA Dr. WAEL ABU ARAFEH St. Josep Hospital St. Shaare Zedek Medical Centre ? RENAL INJURY • Rapid deceleration • Blunt trauma • Penetrating low velocity • Penetrating high velocity • Iatrogenic When to suspect renal injury • Any deceleration injury • Stab or other low-velocity penetration in upper abdomen, flank, lower chest • Lower rib fractures • Gunshot anywhere in trunk • Poly-trauma Initial approach • ABC • Trauma kinetics history • Abdomen, chest, back examination, look for rib fractures • If X-ray is taken, mark entry and exit openings Hematuria in GU injury Hematuria is often indicative, BUT 1. Not specific to organ 2. May be absent in serious renal vascular injury due to blunt trauma 3. Doesn’t correlate well with trauma severity Pediatric Patients Children have a high output of catecholamines after trauma. They can show no signs of shock until 50% of blood volume is lost! any degree of hematuria in children require imaging. Imaging – who’s getting CT? • Blunt trauma patients with gross hematuria • Children with micro/gross hematuria • Microhematuria with shock (BP <90) • Al penetrating injuries with any degree of hematuria • Other organs trauma considered Adult patient with blunt injury with microhematuria and not in shock – observe, hold the CT. Imaging – contrast enhanced CT Finding that suggest major injury: • Medial hematoma – vascular injury • Medial urinary extravasation – pelvic rupture, UPJ avulsion • Lack of parenchyma enhancement – arterial injury Classification of renal injuries Classification of renal injury • 95% of all injuries – grade I • 5% grades II – V Renovascular injury • A result of rapid deceleration: Stretch of renal artery Intimal tear Arterial Thrombosis Kidney ischemia Suspected renal injury – what to do? Non – operative management Actually, 98% of all renal injuries can be managed nonoperatively If no indications for surgery but gross hematuria present – admit and observe. Operative management • Absolute indications: 1. Persistent renal bleeding 2. Expanding perirenal hematoma 3. Pulsatile perirenal hematoma • Relative indications: urinary extravasation, nonviable tissue, delayed diagnosis of arterial injury, incomplete staging. Intraoperative imaging • Unexpected retroperineal hematoma • A need for nephrectomy - is other kidney functional? “one-shot” IVP on the table: inject 2ml/kg of contrast and film 10 min later Nephrectomy • If other kidney present and has adequate functioning! – Unstable patient with hypothermia and coagulation problems • Another option – packing the wound, correcting hypothermia, metabolic and coagulation problems and reexploration in 24 hours Ureteral Injury • Iatrogenic injury • Blunt trauma • Penitrating injury Open surgery • Hysterectomy 54% • Colorectal 14% • Pelvic • Abdominovascular Only 1/3 is recognized during surgery… URETER LIGATION STENT INSERTION Recognizing intraoperative ureteral injury • If such an unfortunate event suspected, injection of 1-2 ml of methylene blue into renal pelvis can show leakage (ligation?) • “one-shot” IVP Laparoscopy • Mostly after gynocological procedures, seldom recognized immediately Ureteroscopy can also result in ureteral injury When to suspect ureteral injury? • History of trauma or surgery and: – Fever – Flank pain and low abdominal pain – Peritoneal inflammation signs – Hematuria – Often paralytic ileus Imaging • IVP is the best diagnostic test available, but it’s not sensitive enough too.. • Retrograde ureterography • CT-IVP Treatment – penetrating injury Treatment – penetrating injury • If high velocity transection suspected – debridment of 2 cm above and 2 cm below is required Treatment surgery induced ureteric injury • If recognized immediately – primary uretoroureterostomy vs. nephrectomy • Delayed recognition: retrograde stent, nephrostomy + anterograde stent, nephrostomy and open repair later Bladder injury • Blunt – due to pelvic fracture. Often car-to- man accident • Penetrating – commonly associated with other major abdominal injuries Symptoms and signs • Presence of pelvic trauma • Hematuria • Low abdominal pain • Unable to urinate • Pelvic hematoma Late recognition • Fever • Urinary retention • Peritoneal signs • ARF Diagnosis • Two step retrograde cystography (filling and voiding) • CT with contrast material through catheter Classification of bladder injury • Contusion • Extraperitoneal – most of serious injuries • Intraperitoneal • Combined Treatment • Contusion (hematuria only) – just observe • Extraperitoneal – percutaneous dranaige only unless: – Bone fragments – Open pelvic fracture – Rectal perforation – Need for surgery for other reasons • Intraperitoneal – surgery After 10 days – cystography. If no extravasation – remove the catheter Injury to urethra prostatic membranous bulbar pendulous Posterior urethra injuries – causes • Blunt pelvic trauma and pelvic fractures Symptoms and Signs • Blood at the urethral meatus. Do not, do not, do not try to pass the catheter if it’s present!!! • Inability to urinate • Palpapable bladder • Pelvic hematoma • Superiorly dispalced prostate Diagnosis • Immediate retrograde urethrogam. Posterior urethra laceration Posterior urethra transection Posterior urethra –complete tear DD • Bladder rupture can be associated with urethral trauma, and it can present same symptomatology Treatment • Suprapubic cystotomy • If incomplete laceration – spontaneous healing in 2-3 weeks • Complete laceration – reconstruction after 3 months • Primary repair – not recommended. Surgery is difficult because of hematomas and impotence rates about 50% Suspected low UT injury – what to do and what not to do? Conclusion • No Foley if you suspect urethral trauma • Gross hematuria OR microhematuria + Shock = GU Trauma. • Pelvic # + Microhematuria GU investigation • Don’t remove Foley if you suspect a partial tear of urethra afterwards. • Microhematuria alone : No imaging …but F/U. • In peds: Imaging for ALL hematuria.
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