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- 1. Urological Trauma Presented by : Ms. Thuen Ms. Leelavady Mr. Latthaphon Ms. Sirisawanh Ms. Fongsamouth
- 2. Outline • Anatomy • Epidemiology • Renal injury • Ureteral injury • Bladder injury • Urethral injury
- 3. Upper urinary tract ₋ ₋ Kidneys Ureters Lower urinary tract ₋ ₋ Bladder Urethra
- 4. EPIDEMIOLOGY (2021) Urological trauma is seen in both sexes and in all age group, but is more common in males. → The renal is the most commonly injured organ in the urinary system; renal trauma is seen in up to 5% of all trauma cases and in 10% of all abdominal trauma cases → Ureteral trauma is relatively rare (1%) → Traumatic bladder injuries : extraperitoneal (65%) and intraperitoneal (25%) → The urethra trauma (4%)
- 5. Anatomy of Urinary tract
- 7. Ureter 25-30 cm Ureteral orifice 3 parts of ureter: Upper, Middle, Lower 1.Ureteropelvic Junction (UPJ) 2.Ureterovesical junction(UVJ)
- 9. Urethra
- 10. Renal Injury • Injury to the kidney caused by an outside force. • The most commonly injured urologic organ. • There are two types of trauma blunt and penetrating.
- 11. • Classified by the mechanism of injury • Blunt injury: - Vehicle accident - Fall - Sports injury • Penetrating injury: - Bullet - Knife - Any object piercing the body TYPES OF RENAL TRAUMA
- 12. • Hematuria (>5 cell per HPF) • Abdominal tenderness • Abdominal abrasions , Bruit • Ribs fracture • Hypotensive (Systolic <90 mmHg) • Shock • Abdominal pain • Low back pain • Nausea • Vomit SIGN & SYMPTOM
- 13. • History of accident • Sign and Symptom • Physical Examination • Laboratory • Imaging DIAGNOSIS OF RENAL INJURY
- 14. • Penetrating trauma (abdomen, flank or lower chest) • Blunt trauma with significant mechanism • Blunt trauma with shock (systolic<90mmhg) • Blunt trauma with hematuria • Pediatric with hematuria (>5cell/high power field) INDICATION FOR RENAL IMAGING
- 15. • CT: (Computed Tomography) - Gold standard method • IVP: (Intravenous Pyelography) - Less effective • MRI: - Cost and Increased imaging time • Angiography: - Embolization in penetrating injury • Ultrasound: RENAL INJURY RADIOLOGY
- 16. • Grade I: Subcapsular hematoma non-expanding Contusions and small infarcts No parenchymal laceration • Grade II: Less than 1cm laceration Non- expanding perirenal hematoma • Grade III: Greater than 1cm laceration Not extending to collecting system • Grade IV: GRADE OF RENAL INJURY AAST
- 17. CT Scan (Computed Tomography)
- 18. MANAGEMENT
- 19. MANAGEMENT
- 21. Ureteral Injury Overall, a ureteral injury is rare. The most common cause is iatrogenic trauma during open surgery, laparoscopic, or endoscopic procedures. Penetrating trauma accounts for most non- iatrogenic ureteral injuries.
- 22. Blunt injury Penetrating injury Iatrogenic injury Penetrating ureteral trauma is the most after com from gunshot or stab wound. • Hyperextension of spine • Lumbar process rupture • Thoracolumbar spine injury • Fall from height the ureter can be injured during pelvic surgery • Gynecology • General surgery • Vascular surgery • Ureteroscopy Etiolog y
- 23. • The iatrogenic injury is usually not be recognized at time of surgery. More often, a delayed diagnosis is made when leakage of urine from the wound drain or vagina is noted • Nonspecific features include - abdominal or flank pain. - infection/sepsis - Hematuria - vomiting and signs of urinary obstruction (hydronephrosis and reduced renal function). Clinical features
- 24. • Ultrasound • Intravenous pyelogram • CT abdomen with contrast • Retrograde pyelography Imaging
- 25. Grade of Ureteral injury AAST
- 26. Partial tear • Ureteral stent • Percutaneous nephrostomy tube Complete tear • Upper ureter – Direct ureteroureterostomy – Tran ureteroureterostomy • Middle ureter – Direct ureteroureterostomy – Tran ureteroureterostomy – Boari flap • Lower ureter – Reimplantation – Psoas hitch Managemen t
- 28. Reimplantation
- 29. Bladder Injury
- 30. • The bladder is an intra-pelvic organ • It becomes intra-abdominal while full • Bladder trauma is an uncommon injury that can be caused by direct blow to a distended bladder, high energy injury which disrupts the pelvis, penetrating and iatrogenic injuries Definition
- 31. ETIOLOGY Motor vehicle accidents Bony fragement Gynea and obs procedures TURB Falls Gun shot Urological procedures TURP Pelvic crush Stab General surgical procedures Blow to lower abdomen Warfare injuries
- 32. • Suprapubic pain or tenderness (Lower abdominal pain) • Gross hematuria/macroscopic hematuria (95%) or microscopic hematuria (5%) • Suprapubic or peritoneal ecchymosis • Abdominal distension • Abdominal guarding or rigidity or ileus • Urinary retention SIGN AND SYMPTOM
- 33. The American association for the surgery of trauma (AAST) proposes a classification of bladder trauma Based on the extent and location of the injury Intraperitoneal Extraperitoneal Combined intra-extraperitoneal • • • Based on mode of action Non-iatrogenic trauma Blunt Penetrating Iatrogenic trauma External Internal Foreign body • - - • - - - CLASSIFICATION
- 35. • History taking • Physical examination • Investigation : • Cystogram (Gold standard) • Cystoscopy • Abdominal ultrasound • Radiology : CT scan, MRI • IVP • UA • Hematology examination Diagnosis
- 36. Management I II Hematoma Contusion, intramural hematoma Observation Laceration Partial thickness Repair, Foley catheter drainage Laceration Extraperitoneal bladder wall laceration < 2 cm Repair, Foley catheter drainage III Laceration Extraeitoneal (<2cm) or intraperitoneal (<2cm) bladder wall laceration Repair, Foley catheter drainage IV Laceration Intraperitoneal bladder wall laceration > 2 cm Repair, Foley catheter drainage V Laceration Intraperitoneal or extraperitoneal bladder wall laceration extending into the bladder neck or ureteral orifice (trigone) Repair, Foley catheter drainage, ureteral repair +- stent
- 38. Urethral Injury -Anterior urethral injury: The bulbar urethral is the most common site affected by blunt trauma, Iatrogenic injury is the most common type of urethral trauma -Posterior urethral injuries Blunt posterior urethral injuries (membranous) are almost exclusively related to pelvic fractures
- 39. • Female urethral injuries • Birth related injuries to the female urethra are rare and consist of minor (peri)urethral lacerations during vaginal • Delivery • Urethral Injury
- 40. Classification
- 41. • • • • • • History taking Rectal examination Investigation Retrograde urethrography (RUG) Cysto-urethroscopy Ultrasound abdominal pelvic and magnetic resonance imaging Diagnosis
- 42. • • • • • • Immediate exploration Antibiotic Analgesic Urethral reconstruction Urinary diversion Urethroplasty Management
- 43. REFFERENC E