10 genitourinary trauma

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10 genitourinary trauma

  1. 1. Genitourinary TraumaProf. DR. Mohamed ShafikProf. DR. Mohamed ShafikUrology Department – Alexandria University
  2. 2. • ~10% of E.R. trauma visits• Often associated with multi-system trauma• Subtle presentations, easily overlooked• Diseased GU organs susceptible to injuryGU TraumaObjectives
  3. 3. • ~10% of E.R. trauma visits• Often associated with multi-system trauma• Subtle presentations, easily overlooked• Diseased GU organs susceptible to injuryGU TraumaGeneral Considerations
  4. 4. • Airway• with C-spine protection• Breathing• Circulation• control of external hemorrhage, 2 large bore IVs• Disability• assessment of neurologic status• Exposure / Environment• undress / temperature controlGU TraumaEvaluation
  5. 5. • Most commonly injured GU organ• Often in association with multi-system organinjury• Blunt >80%• Penetrating <20%Renal TraumaGeneral Considerations
  6. 6. • Most common form of renal trauma• Types of injury– Motor vehicle accidents– Falls from heights– Assaults• Mechanisms of injury– High velocity impact (contusion / hematoma / laceration)– Deceleration injury (RA thrombosis / RV disruption /avulsion of renal pedicle)Renal TraumaBlunt
  7. 7. • Uncommon form of renal trauma• Types of injury– Gunshot wounds– Stab wounds• Mechanisms of injury– Direct shearing force through renal tissueRenal TraumaPenetrating
  8. 8. • Hematuria (gross or microscopic)– Microscopic = 5 RBCs/HPF– May be absent• Shock (hypotension, tachycardia, oliguria)• Flank bruising/mass• Flank pain/tendernessRenal TraumaPresentation
  9. 9. • Penetrating injuries• Blunt injuries in association with:– Gross hematuria– Microscopic hematuria and shock (SBP < 90)– Microscopic hematuria in children– Microscopic hematuria in patient with solitary kidney– Absence of hematuria but high clinical index of suspicionof renal injury based on Hx, Px and AXR• Rapid deceleration injury• Lower rib #• Transverse process #• Loss of psoas shadowRenal TraumaIndications for Imaging
  10. 10. Consider the need for both anatomic and functional information• IVP - “Single-shot” intra-op• U/S - Confirm 2 kidneys• Angiography - Used for embolizationThese modalities have a limited role and have been essentiallyreplaced by CT scanRenal TraumaOptions for Imaging
  11. 11. • Provides valuable anatomic and functional information• Provides the most definitive staging information• Provides information on associated injuries• Imaging modality of choice for renal traumaRenal TraumaCT Scan
  12. 12. • Urinary extravasation medial to kidney– Suggests UPJ avulsion or renal pelvic injury• Hematoma medial to kidney, displacing it laterally– Suggests pedicle injury• Lack of contrast enhancement of kidney– Suggests arterial injuryRenal TraumaCT Findings – Major Trauma
  13. 13. • Many classification systems available• Recommend:– American Association for the Surgery of Trauma (AAST)Organ Injury Severity Scale• Because:– Most widely used– In Campbell’sRenal TraumaClassification
  14. 14. AASTRenal TraumaClassification
  15. 15. Pediatric Renal TraumaConsiderations• Occupies proportionately larger space• Less perirenal and subcutaneous fat• Renal capsule, Gerota’s fascia and perirenal fat lessdeveloped (? less fixation)• Vascular pedicle more susceptible to shearing forces• Higher catecholamine output after trauma
  16. 16. Pediatric Renal TraumaControversies• What is appropriate investigation of suspectedrenal injuries?• What is the significance of degree of hematuria?• Does the rule of microscopic hematuria and shockstill fit?
  17. 17. Pediatric Renal TraumaSummary• Shock not a useful parameter• Hematuria may not be present ~10%• Not all children with blunt trauma need to beevaluated but...• High index of suspicion based on mechanism• “Liberal” use of imaging studies
  18. 18. • Conservative management for:– 90-98% of blunt renal trauma– Up to 50% of penetrating renal trauma• ABCs• Admission• Bedrest until gross hematuria clears• Close clinical observation– Serial vital signs, CBCRenal TraumaNon-operative Management
  19. 19. ABSOLUTE• Persistent renal bleedingwith hemodynamicinstability• Expanding perirenalhematoma• Pulsatile perirenalhematomaRenal TraumaIndications for Surgical ExplorationRELATIVE• Penetrating injuries• Extensive urineextravasation• Grade 5 injury– “Shattered kidney”– Pedicle injury• Non-viable tissue (>20%)• Arterial injury (main or
  20. 20. • Transabdominal midline laparotomy• Early control of renal vessels• Exposure of kidney– Open Gerota’s fascia– Dissect kidney from surrounding hematoma• Decision: repair of kidney vs. removal of kidneyRenal TraumaPrinciples of Surgical Exploration
  21. 21. • Complete renal exposure• Debridement of non-viable tissue• Hemostasis– Suture ligature– Gelfoam, Surgicel– Argon beam coagulation• Water-tight closure of collecting systemRenal TraumaPrinciples of Renal Reconstruction
  22. 22. Renal TraumaTechnique of Renal Reconstruction
  23. 23. • Early– Hemorrhage, shock– Urinoma• Late– Infection– Loss of renal function– Hypertension• BP checks with family doctorRenal TraumaComplications
  24. 24. • Relatively uncommon• Often in association with multi-system organ injury• Significant mortality rate (10-20%)• Have high index of suspicion of urethral disruptioninjury• Bladder more susceptible to injury when fullBladder TraumaGeneral Considerations
  25. 25. • Blunt• Penetrating• Iatrogenic• Spontaneous ruptureBladder TraumaEtiology
  26. 26. BLUNT• Most common type of bladder injury• Usually motor vehicle accidents• 2/3 contusions, 1/3 ruptures• Associated with pelvic #– 10-25% of pelvic #’s have associated bladder injury– 85-90% of bladder injuries have associated pelvic #PENETRATING• Less common• Often associated with major organ injuriesBladder TraumaEtiology
  27. 27. IATROGENIC• Open or laparoscopic pelvic surgery– Gynecologic, vascular, urologic or general surgerySPONTANEOUS RUPTURE• Underlying pathology– Cancer, obstruction, XRT, TB, sensory neurologic deficitBladder TraumaEtiology
  28. 28. • Hematuria– 95% blunt injuries have gross hematuria• Inability to void• Abdominal pain• Abdominal bruising• Pelvic mass• Peritoneal signs• ShockBladder TraumaPresentation
  29. 29. • Cystogram– AP films ± obliques– Remember drainage films• 10% of bladder ruptures detected on drainage films• CT Cystogram– Often more efficient since most patients need CT anyway– Provides additional helpful information about other organsBladder TraumaImaging
  30. 30. • Grade 1: Hematoma (contusion, intramural hematoma)Laceration (partial thickness)• Grade 2: Laceration (extraperitoneal, <2cm)• Grade 3: Laceration (extraperitoneal, ≥2cm)Laceration (intraperitoneal, <2cm)• Grade 4: Laceration (intraperitoneal, ≥2cm)• Grade 5: Laceration (intra- or extraperitoneal, extending into bladderneck, ureteral orifice, trigone)Advance one grade for multiple injuries up to grade 3Bladder TraumaAAST Organ Injury Severity Scale
  31. 31. • Contusion– Most common– Often diagnosis of exclusion• Laceration/rupture– Extraperitonealvs. This is what we really need to know– IntraperitonealBladder TraumaPractical Classification
  32. 32. GENERAL PRINCIPLES• ABCs• Establish urinary drainage/diversion• AntibioticsCONTUSION– No specific therapy requiredBladder TraumaManagement
  33. 33. EXTRAPERITONEAL RUPTURE• Conservative, catheter drainage x 7-14 days,cystogram• Indications for surgical repair:– Patient already in O.R. for another reason– Associated rectal perforation or open pelvic fracture– Bone fragments projecting into bladder– Multiple/large rupturesBladder TraumaManagement
  34. 34. INTRAPERITONEAL RUPTURE• Surgical repair– Midline laparotomy/cystotomy– Multi-layer closure of bladder injury– Bladder drainage• Foley catheter ± suprapubic catheter– Perivesical drainBladder TraumaManagement
  35. 35. • Intraperitoneal– Urinary frequency– Shock– Peritonitis– Azotemia• Extraperitoneal– Shock– Pelvic abscessBladder TraumaComplications
  36. 36. • 46 y/o woman undergoes TAH-BSO for severeendometriosis– Significant bleeding intra-op, requires 4 units pRBCs• POD# 4:– Still not able to tolerate solids– C/o R flank pain– T=38.6°C• What would you do now?Case #3
  37. 37. R kidneyL kidney
  38. 38. • External trauma very rare– <4% of penetrating trauma– <1% of blunt trauma– Look for concomitant visceral injuries (SB, LB, K, B)• Usually surgical trauma– Gynecologic, vascular, urologic or general surgery• Open• Laparoscopic– UreteroscopyUreteral TraumaEtiology
  39. 39. • At time of external trauma• If unrecognized intra-op, then:– Low grade fever, ileus– Flank pain– Fluid drainage from incision, drain sites• Hematuria may be absentUreteral TraumaPresentation
  40. 40. • Methylene blue– IV or renal pelvic injection– For suspected intra-op ureteral injury– Allows localization of injury• IVP• CT scan• Ureteropyelogram– Retrograde– AntegradeUreteral TraumaDiagnostic Tests and Imaging
  41. 41. • Grade 1: Contusion (without devascularization)Hematoma (without devascularization)• Grade 2: Laceration (<50% transection)• Grade 3: Laceration (≥50% transection)• Grade 4: Laceration (complete transection with <2cm devascularization)• Grade 5: Laceration (avulsion with >2cm devascularization)Advance one grade for bilateral injuries up to grade 3Ureteral TraumaAAST Organ Injury Severity Scale
  42. 42. • Factors to consider in determining treatment:– Etiology– Level of ureter involved– Immediate vs delayed Dx– Severity (contusion vs. complete transection)– Clinical status of patient• Temporary PCN• Remove suture/clip• Ureteral stent insertionUreteral InjuryManagement
  43. 43. • Ureteroneocystostomy– ± Psoas hitch– ± Boari flap• Ureteroureterostomy• Transureteroureterostomy• Renal descensus• Ileal interposition• Autotransplantation• Nephrectomy (last resort)Ureteral InjurySurgical Options
  44. 44. • Early– Hydronephrosis– Urinoma– Infection• Late– Stricture– Loss of renal function– Stone formationUreteral InjuryComplications
  45. 45. • Usually due to blunt trauma– Sports, fights• Testis involved in 1-2% of gunshot wounds• Pain, scrotal hematoma, bruising• Physical exam often difficult due to pain anddegree of swelling• U/S most useful investigation– To determine if ruptured– May miss tunical fractureTestis Trauma
  46. 46. • Grade 1: ContusionHematoma• Grade 2: Subclinical laceration of tunica albuginea• Grade 3: Laceration of TA with <50% parenchymal loss• Grade 4: Major laceration of TA with ≥50% parenchymal loss• Grade 5: Total testicular destruction or avulsionAdvance one grade for bilateral injuries up to grade 5Testis TraumaAAST Organ Injury Severity Scale
  47. 47. • Most cases are low grade injuries (contusions orhematomas) and are therefore managed non-operatively– Ice, analgesics, bedrest/activity restrictions• Indications to operate:– Rupture of tunica albuginea– Expanding or large hematocele– Intratesticular hematoma• Surgery– Repair vs. orchidectomyTesticular salvage rate higher for early explorationTestis TraumaManagement

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