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Retroperitoneal Collections; Causes , Diagnosis and Management Dr Maha Khalid AL Madi Urology Resident KFHU – Khobar – Sau...
Objective… <ul><li>Retroperitoneal anatomy </li></ul><ul><li>Interfascial planes </li></ul><ul><li>Interfascial plane exte...
Retroperitoneal Anatomy
Retroperitoneal Anatomy <ul><li>The retroperitoneum is conventionally divided into  three  distinct compartments: </li></ul>
Retroperitoneal Anatomy <ul><li>1 . Posterior pararenal space,  </li></ul><ul><li>Fat  </li></ul><ul><li>connective tissue...
Retroperitoneal Anatomy <ul><li>2 . Anterior pararenal space </li></ul><ul><li>Colon </li></ul><ul><li>Pancreas </li></ul>...
Retroperitoneal Anatomy <ul><li>3. Perirenal space  </li></ul><ul><li>Kidneys </li></ul><ul><li>Adrenal glands </li></ul><...
Interfascial Planes
Interfascial Planes <ul><li>Tricompartmental anatomy does not completely explain the spread of fluid collections. </li></u...
Interfascial Planes <ul><li>These interfascial planes are represented by </li></ul><ul><li>- Retromesenteric </li></ul><ul...
Interfascial Planes <ul><li>The Retromesenteric plane </li></ul><ul><li>  Expansile plane located between the APR and PRS ...
Interfascial Planes <ul><li>The Retrorenal plane   </li></ul><ul><li>Between the PRS and PPS </li></ul>
Interfascial Planes <ul><li>The lateral conal interfascial plane   </li></ul><ul><li>Between layers of the LCF. It communi...
Interfascial Planes <ul><li>The combined interfascial plane   </li></ul><ul><li>formed by the inferior blending of the  RM...
Interfascial Planes <ul><li>The fascial trifurcation   </li></ul><ul><li>The point at which the RMP, RRP, and  LCF planes ...
Interfascial Plane Extensions
Interfascial Planes <ul><li>Medial Extension  </li></ul><ul><li>RMPs and RRS are continuous across the midline. </li></ul>
Interfascial Planes <ul><li>Right superior extension </li></ul><ul><li>The superior PRS is in continuity with the bare are...
Interfascial Planes <ul><li>Left superior extension </li></ul><ul><li>The RMP ,RRP and PRS on the left extend to the left ...
Retroperitoneal collections & their extensions
Types of Collections <ul><li>- hemorrhagic </li></ul><ul><li>- bilious </li></ul><ul><li>- uriniferous  </li></ul><ul><li>...
Extension of fluid collections <ul><li>Fascial planes/adhesions confine retroperitoneal fluid collections to their  compar...
Extension of fluid collections <ul><li>Fluid originating from the APS </li></ul><ul><li>Pancreatitis Pancreatic injury App...
Extension of fluid collections <ul><li>Fluid originating from the PRS </li></ul><ul><li>Ruptured AAA  </li></ul><ul><li>Re...
Extension of fluid collections <ul><li>Fluid originating from the PPS </li></ul><ul><li>bleeding after spinal trauma/surge...
Extension of fluid collections <ul><li>Pelvic Extension </li></ul><ul><li>By the  infrarenal retroperitoneal space </li></ul>
Retroperitoneal Hematomas
Causes factor IX ,X deficiency, von Willebrand  APL syndrome anticoagulation* *0.6-6.6% of patients undergoing therapeutic...
Great Vessel Injuries <ul><li>Rupture of AAA </li></ul><ul><li>Most bleed  posteriorly  confined by the psoas space or ext...
Great Vessel Injuries <ul><li>IVC Injury </li></ul><ul><li>Often found to bleed directly into the  right retrorenal space ...
Perirenal Hematomas <ul><li>Renal trauma (incidence 5%)* </li></ul><ul><li>Helical CT  is the imaging modality of choice i...
Perirenal Hematomas <ul><li>Hematoma from the PRS spreads by  bridging septa  to the  interfascial planes </li></ul><ul><l...
Pelvic fracture w/ Hematoma <ul><li>2 Routes of spread are possible </li></ul><ul><li>- from the  PPS  into the combined  ...
Pelvic fracture w/ Hematoma <ul><li>Can then ascend within the  combined interfascial plane  into the </li></ul><ul><li>  ...
Approach to RPH
Approach to RPH <ul><li>The location and mechanism of injury guide the decision to explore </li></ul><ul><li>the midline r...
Approach to RPH ZONE 1 ZONE 2 ZONE 3
Approach to RPH <ul><li>zone I </li></ul><ul><li>Mandates exploration for both penetrating and blunt injury because of the...
zone I (central) retroperitoneal hematoma with active extravasation from ruptured AAA
Approach to RPH <ul><li>zone II </li></ul><ul><li>injury to the renal vessels or parenchyma and mandates exploration for  ...
  Large zone II (lateral) retroperitoneal hematoma From renal injury
Approach to RPH <ul><li>zone III </li></ul><ul><li>Penetrating  trauma mandates exploration </li></ul><ul><li>Blunt  traum...
Approach to RPH <ul><li>Clinical Presentation </li></ul><ul><li>Is varied ,may be vague, and diagnosis is often missed </l...
Approach to RPH <ul><li>Clinical Presentation </li></ul><ul><li>Patients may present with back, lower abdominal or groin d...
Approach to RPH <ul><li>Diagnostic Imaging </li></ul><ul><li>Plain abdominal /pelvic XRAY may demonstrate ; </li></ul><ul>...
Approach to RPH <ul><li>Diagnostic Imaging </li></ul><ul><li>Ultrasound is often limited  </li></ul><ul><li>Free fluid oft...
Approach to RPH <ul><li>Diagnostic Imaging </li></ul><ul><li>CT  (type, site and extent of fluid collections ( </li></ul><...
Approach to RPH <ul><li>Diagnostic Imaging </li></ul><ul><li>In haemodynamically unstable,  digital subtraction angiograph...
Approach to RPH <ul><li>Management </li></ul><ul><li>Controversial.  </li></ul><ul><li>all patients should initially be ma...
Approach to RPH <ul><li>Management </li></ul><ul><li>If the patient is haemodynamically stable with no evidence of on-goin...
Approach to RPH <ul><li>Management </li></ul><ul><li>In spontaneous RPH the mainstay of management remains conservative,  ...
Approach to RPH <ul><li>Endovascular Treatment </li></ul><ul><li>Selective intra-arterial embolization OR stent-grafts. </...
Approach to RPH <ul><li>Open Surgery </li></ul><ul><li>Indications </li></ul><ul><li>- the patient remains unstable  </li>...
Approach to RPH <ul><li>RPH (Zone 1) after penetrating trauma implies injury to the great vessels and  always  requires ur...
Approach to RPH <ul><li>RPH in  other zones  should be evaluated by CT and/or angiography; ongoing hemorrhage may respond ...
Thank You
References… <ul><li>Comprehensive reviews of the interfascial plane of the retroperitoneum: normal anatomy and pathologic ...
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Retroperitoneal Collections

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Retroperitoneal Collections

  1. 1. Retroperitoneal Collections; Causes , Diagnosis and Management Dr Maha Khalid AL Madi Urology Resident KFHU – Khobar – Saudi Arabia 2010
  2. 2. Objective… <ul><li>Retroperitoneal anatomy </li></ul><ul><li>Interfascial planes </li></ul><ul><li>Interfascial plane extensions </li></ul><ul><li>Retroperitoneal collections & extension </li></ul><ul><li>Retroperitoneal Hematoma </li></ul><ul><li>- Causes </li></ul><ul><li>- Approach to RPH </li></ul><ul><li>- Diagnostic imaging </li></ul><ul><li>- Management </li></ul>
  3. 3. Retroperitoneal Anatomy
  4. 4. Retroperitoneal Anatomy <ul><li>The retroperitoneum is conventionally divided into three distinct compartments: </li></ul>
  5. 5. Retroperitoneal Anatomy <ul><li>1 . Posterior pararenal space, </li></ul><ul><li>Fat </li></ul><ul><li>connective tissue nerves </li></ul>
  6. 6. Retroperitoneal Anatomy <ul><li>2 . Anterior pararenal space </li></ul><ul><li>Colon </li></ul><ul><li>Pancreas </li></ul><ul><li>Duodenum </li></ul>
  7. 7. Retroperitoneal Anatomy <ul><li>3. Perirenal space </li></ul><ul><li>Kidneys </li></ul><ul><li>Adrenal glands </li></ul><ul><li>Upper portion of ureters </li></ul><ul><li>  </li></ul>
  8. 8. Interfascial Planes
  9. 9. Interfascial Planes <ul><li>Tricompartmental anatomy does not completely explain the spread of fluid collections. </li></ul><ul><li>Collections tend to escape site of origin into expandable interfascial planes. </li></ul>
  10. 10. Interfascial Planes <ul><li>These interfascial planes are represented by </li></ul><ul><li>- Retromesenteric </li></ul><ul><li>- Retrorenal </li></ul><ul><li>- Lateroconal interfascial plane, </li></ul><ul><li>- Combined interfascial planes </li></ul>
  11. 11. Interfascial Planes <ul><li>The Retromesenteric plane </li></ul><ul><li> Expansile plane located between the APR and PRS </li></ul>
  12. 12. Interfascial Planes <ul><li>The Retrorenal plane </li></ul><ul><li>Between the PRS and PPS </li></ul>
  13. 13. Interfascial Planes <ul><li>The lateral conal interfascial plane </li></ul><ul><li>Between layers of the LCF. It communicates with the RMP and RRP at the fascial trifurcation. </li></ul>
  14. 14. Interfascial Planes <ul><li>The combined interfascial plane </li></ul><ul><li>formed by the inferior blending of the RMP and RRP . It continues into the pelvis. </li></ul>
  15. 15. Interfascial Planes <ul><li>The fascial trifurcation </li></ul><ul><li>The point at which the RMP, RRP, and LCF planes communicate mutually </li></ul>
  16. 16. Interfascial Plane Extensions
  17. 17. Interfascial Planes <ul><li>Medial Extension </li></ul><ul><li>RMPs and RRS are continuous across the midline. </li></ul>
  18. 18. Interfascial Planes <ul><li>Right superior extension </li></ul><ul><li>The superior PRS is in continuity with the bare area of the liver </li></ul>
  19. 19. Interfascial Planes <ul><li>Left superior extension </li></ul><ul><li>The RMP ,RRP and PRS on the left extend to the left hemidiaphragm </li></ul>
  20. 20. Retroperitoneal collections & their extensions
  21. 21. Types of Collections <ul><li>- hemorrhagic </li></ul><ul><li>- bilious </li></ul><ul><li>- uriniferous </li></ul><ul><li>- enteric </li></ul><ul><li>- infectious </li></ul><ul><li>- inflammatory </li></ul><ul><li>- malignant </li></ul>
  22. 22. Extension of fluid collections <ul><li>Fascial planes/adhesions confine retroperitoneal fluid collections to their compartment of origin </li></ul><ul><li>Large or rapidly developing fluid collections may decompress along retroperitoneal fascial planes </li></ul>
  23. 23. Extension of fluid collections <ul><li>Fluid originating from the APS </li></ul><ul><li>Pancreatitis Pancreatic injury Appendicitis abscess of the colonic wall </li></ul>
  24. 24. Extension of fluid collections <ul><li>Fluid originating from the PRS </li></ul><ul><li>Ruptured AAA </li></ul><ul><li>Renal injury Hge/urinoma </li></ul>
  25. 25. Extension of fluid collections <ul><li>Fluid originating from the PPS </li></ul><ul><li>bleeding after spinal trauma/surgery </li></ul>
  26. 26. Extension of fluid collections <ul><li>Pelvic Extension </li></ul><ul><li>By the infrarenal retroperitoneal space </li></ul>
  27. 27. Retroperitoneal Hematomas
  28. 28. Causes factor IX ,X deficiency, von Willebrand APL syndrome anticoagulation* *0.6-6.6% of patients undergoing therapeutic anticoagulation. Management of Spontaneous and Iatrogenic Retroperitoneal Haemorrhage: nt J Clin Pract. 2008; Injury ( to bony structures, major vessels, intestinal or retroperitoneal viscera) Iatrogenic
  29. 29. Great Vessel Injuries <ul><li>Rupture of AAA </li></ul><ul><li>Most bleed posteriorly confined by the psoas space or extend into the retrorenal interfascial plane behind the left kidney. </li></ul>
  30. 30. Great Vessel Injuries <ul><li>IVC Injury </li></ul><ul><li>Often found to bleed directly into the right retrorenal space . </li></ul>
  31. 31. Perirenal Hematomas <ul><li>Renal trauma (incidence 5%)* </li></ul><ul><li>Helical CT is the imaging modality of choice in stable patients </li></ul><ul><li>* Management of Spontaneous and Iatrogenic Retroperitoneal Haemorrhage: </li></ul><ul><li>nt J Clin Pract. 2008; </li></ul>
  32. 32. Perirenal Hematomas <ul><li>Hematoma from the PRS spreads by bridging septa to the interfascial planes </li></ul><ul><li>From there can spread upward near the esophagus or downward to the pelvis </li></ul>
  33. 33. Pelvic fracture w/ Hematoma <ul><li>2 Routes of spread are possible </li></ul><ul><li>- from the PPS into the combined interfascial plane, </li></ul><ul><li>- from the prevesical space to the combined interfascial plane. </li></ul>
  34. 34. Pelvic fracture w/ Hematoma <ul><li>Can then ascend within the combined interfascial plane into the </li></ul><ul><li> RRS </li></ul><ul><li> RMP </li></ul>
  35. 35. Approach to RPH
  36. 36. Approach to RPH <ul><li>The location and mechanism of injury guide the decision to explore </li></ul><ul><li>the midline retroperitoneum (zone 1) </li></ul><ul><li>the perinephric space (zone 2) </li></ul><ul><li>the pelvic retroperitoneum (zone 3) </li></ul>
  37. 37. Approach to RPH ZONE 1 ZONE 2 ZONE 3
  38. 38. Approach to RPH <ul><li>zone I </li></ul><ul><li>Mandates exploration for both penetrating and blunt injury because of the high likelihood of major vascular injury in this area. </li></ul>
  39. 39. zone I (central) retroperitoneal hematoma with active extravasation from ruptured AAA
  40. 40. Approach to RPH <ul><li>zone II </li></ul><ul><li>injury to the renal vessels or parenchyma and mandates exploration for penetrating trauma </li></ul><ul><li>A nonexpanding stable hematoma resulting from a blunt trauma mechanism is better left unexplored </li></ul>
  41. 41.   Large zone II (lateral) retroperitoneal hematoma From renal injury
  42. 42. Approach to RPH <ul><li>zone III </li></ul><ul><li>Penetrating trauma mandates exploration </li></ul><ul><li>Blunt trauma are usually with pelvic fractures management is based external fixation or angiographic embolization </li></ul>
  43. 43. Approach to RPH <ul><li>Clinical Presentation </li></ul><ul><li>Is varied ,may be vague, and diagnosis is often missed </li></ul><ul><li>Patients initially exhibit subtle clinical signs of hypotension and mild tachycardia that transiently improves with administration of fluids. </li></ul>
  44. 44. Approach to RPH <ul><li>Clinical Presentation </li></ul><ul><li>Patients may present with back, lower abdominal or groin discomfort and swelling, </li></ul><ul><li>May progress to haemodynamic instability. </li></ul>
  45. 45. Approach to RPH <ul><li>Diagnostic Imaging </li></ul><ul><li>Plain abdominal /pelvic XRAY may demonstrate ; </li></ul><ul><li>loss of the psoas shadow unstable pelvic ring fracture </li></ul>
  46. 46. Approach to RPH <ul><li>Diagnostic Imaging </li></ul><ul><li>Ultrasound is often limited </li></ul><ul><li>Free fluid often passes into the abdominal or pelvic cavity, and can be detected as free abdominal fluid on US </li></ul>
  47. 47. Approach to RPH <ul><li>Diagnostic Imaging </li></ul><ul><li>CT (type, site and extent of fluid collections ( </li></ul><ul><li>CT Angio shows the site of the bleed and contrast outside the vessels </li></ul>
  48. 48. Approach to RPH <ul><li>Diagnostic Imaging </li></ul><ul><li>In haemodynamically unstable, digital subtraction angiography with selective embolisation or placement of a stent graft is indicated. </li></ul>
  49. 49. Approach to RPH <ul><li>Management </li></ul><ul><li>Controversial. </li></ul><ul><li>all patients should initially be managed in an intensive care unit with careful monitoring, fluid resuscitation, blood transfusion and normalization of coagulation profile </li></ul>
  50. 50. Approach to RPH <ul><li>Management </li></ul><ul><li>If the patient is haemodynamically stable with no evidence of on-going bleeding, conservative management is recommended * </li></ul><ul><li>* Management of Spontaneous and Iatrogenic Retroperitoneal Haemorrhage: Iatrogenic Retroperitoneal Bleed by .C. Chan,1 J.P. Morales,1 J.F. Reidy,2 and P.R. Taylor 1 </li></ul><ul><li>Int J Clin Pract. 2008; </li></ul>
  51. 51. Approach to RPH <ul><li>Management </li></ul><ul><li>In spontaneous RPH the mainstay of management remains conservative, </li></ul><ul><li>withdrawal of anticoagulation </li></ul><ul><li>correction of coagulopathy </li></ul><ul><li>volume resuscitation </li></ul><ul><li>* Management of Spontaneous and Iatrogenic Retroperitoneal Haemorrhage: Iatrogenic Retroperitoneal Bleed by .C. Chan,1 J.P. Morales,1 J.F. Reidy,2 and P.R. Taylor 1 </li></ul><ul><li>Int J Clin Pract. 2008; </li></ul>
  52. 52. Approach to RPH <ul><li>Endovascular Treatment </li></ul><ul><li>Selective intra-arterial embolization OR stent-grafts. </li></ul><ul><li>Indication: HD instability despite ≥ 4 units of blood IN 24 h, or ≥ 6 units in 48 h </li></ul>
  53. 53. Approach to RPH <ul><li>Open Surgery </li></ul><ul><li>Indications </li></ul><ul><li>- the patient remains unstable </li></ul><ul><li>- interventional radiology is not successful or unavailable. </li></ul><ul><li>- patient develops abdominal compartment syndrome </li></ul>
  54. 54. Approach to RPH <ul><li>RPH (Zone 1) after penetrating trauma implies injury to the great vessels and always requires urgent surgical exploration. </li></ul>
  55. 55. Approach to RPH <ul><li>RPH in other zones should be evaluated by CT and/or angiography; ongoing hemorrhage may respond to therapeutic embolization </li></ul>
  56. 56. Thank You
  57. 57. References… <ul><li>Comprehensive reviews of the interfascial plane of the retroperitoneum: normal anatomy and pathologic entities </li></ul><ul><li>Su Lim Lee & Young Mi Ku & Sung Eun Rha </li></ul><ul><li>28 April 2009 Soc Emergency Radiol 2009 </li></ul><ul><li>Cameron: Current Surgical Therapy, 9th ed. By JOHN L. CAMERON, MD, FACS, FRCS </li></ul><ul><li>Sabiston Textbook of Surgery , 18th ed by Beaughamp,Evers, Mattox </li></ul><ul><li>Management of Retroperitoneal Haemorrhage, Y.C. Chan; J.P. Morales; J.F. Reidy; P.R. Taylor, Int J Clin Pract. 2008 </li></ul><ul><li>http://www.medscape.com/viewarticle/582645 </li></ul><ul><li>Traumatic Retroperitoneal Injuries: Review of Multidetector CT Findings 1 October 2008 RadioGraphics </li></ul><ul><li>Kevin P. Daly , MD, Christopher P. Ho , MD, </li></ul>

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