GENITOURINARY TRAUMA - PowerPoint by AmnaKhan

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									GENITOURINARY TRAUMA


 Dr. WAEL ABU ARAFEH
 St. Josep Hospital
 St. Shaare Zedek Medical Centre
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       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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