L.

ARIES FAHROZI

TRAUMA UROGENITAL
Anatomi Ginjal Ureter Buli buli Uretra

TRAUMA UROGENITAL
Anatomi Ginjal Ureter Buli buli Uretra

Ginjal
Sepasang organ seperti kacang
Terletak retroperitonel diregio lumbal superior

Dilapisi oleh 3 lapis jaringan penunjang: kapsul ginjal kapsul adipose dan fasia renalis

Ureter
Tubulus muscular yang menghubungkan ginjal ke buli

buli Terletak di belakang rongga peritoneum (retroperitoneal) Panjang 25 30 cm

TRAUMA GINJAL
Trauma Ginjal

Sering 8-10% trauma tumpul / tajam abdomen Separuh dari kejadian trauma urogenital Di proteksi :

* Otot-otot lumbal * Iga * Vertebrae

Angka kesakitan / kematian ok trauma ginjal tergantung :

Derajat trauma Keterlibatan trauma organ lain Fasilitas penanggulangan trauma

Buli-buli
Buli buli normal dapat menampung 350 450 mL

urine Drainase kendung kemih bermuara ke vena iliaca interna

Uretra
Tabung yang menyalurkan urine ke luar dari buli-buli
Secara anatomis uretra dibagi menjadi 2 bagian : Uretra posterior dan Uretra anterior

Mekanisme Trauma
Trauma tumpul -> penyebab trauma Langsung, tidak langsung
Trauma tumpul langsung KLL Olah raga Kecelakaan kerja Perkelahian

Trauma tumpul tidak langsung * Jatuh dari ketinggian * KLL menyebabkan pergerakan ginjal tiba-tiba dlm rongga retro peritonium Avulsi pedikel ginjal Robekan tunika intima

Bisa juga oleh trauma iatrogenik Pemasangan kateter di atas ureter Pengambilan biopsi ginjal Infeksi tidak langsung Klasifikasi * Ada beberapa macam * Ditentukan oleh luas dan penatalaksanaan

Cedera Ginjal * Minor * Mayor * Vaskuler Cedera Minor 90% trauma ginjal Kontusio ginjal Laserasi parenkim superficial

Cedera Mayor Laserasi korteks, medula tanpa ekstravasasi Laserasi korteks, medula dengan ekstravasasi Cedera Vaskuler Avulsi Trombosis

Berdasarkan AAST ( American for The Surgery of Trauma )

Berdasarkan AAST ( American for The Surgery of Trauma )

Dibagi 5 derajat Derajat 1 Kontusio ginjal /subkapsularhematom Tidak meluas Hematuria dengan normal imaging

Derajat 2 Hematom perineal Tdk meluas ke retroperitonium Laserasi superficial ( < 1cm ) Tdk melibatkan collecting systim Derajat 3 Renal laserasi ( > 2cm ) Sub capsular hematom Perinephric hematom Tdk melibatkan collecting systim

Derajat 4 Laserasi yang meluas ke collecting systim Extravasasi Trauma vasculer segmental infark

Derajat 5 Shattered kidney Devaskularisasi / oklusi / trombosis arteri / vena utama Laserasi komplit Extravasasi UPJ avulsi

Pemeriksaan Radiologi
Foto polos abdomen
IVP ( Intra Vena Pyelografi )

USG ( Ultra Sonographi )

CT Scan abdomen / Whole abdomen

uretrocistografi

IVP * Melihat ekstravasasi urin / kontras * Tidak bisa mendeteksi trauma ginjal derajat I, II * Fungsi ginjal kontra lateral

USG * Melihat hemoperitoneum * Tdk dianjurkan utk evaluasi trauma ginjal * Dengan color doppler melihat vaskuler

CT Scan Pemeriksaan yang sensitif dan spesifik Menentukan derajat trauma Tidak invasif Dpt mengevaluasi organ lain ( hepar , lien , aorta ) kontras non kontras Angiografi Invasif Delayed renal bleeding-pseudo-aneurisma

IVP normal

USG ginjal normal

CT scan ginjal normal

Gambar 1. Kidney trauma. Absent nephrogram. Abdominal radiograph after intravenous contrast administration in a patient with hypotension after a motor vehicle collision shows absent right nephrogram

Gambar 2. Kidney trauma. Grade 3 renal laceration on abdominal radiograph. Abdominal radiograph after intravenous contrast administration shows very diminished left nephrogram and no urinary contrast extravasation

Gambar 3. Kidney trauma. Grade 5 renal injury. Shattered kidney with renal vein thrombosis (incomplete). Abdominal radiograph after intravenous contrast administration shows absent right nephrogram

Gambar 4 Kidney trauma. Grade 1 renal injury, contusion. Image from a contrast-enhanced CT scan of the abdomen in a patient with hematuria after a motor vehicle collision shows ill-defined area of hypoenhancement in the medial right kidney.

Gambar. 5. Kidney trauma. Grade 1 renal injury, subcapsular hematoma. CT scan of the abdomen with intravenous contrast in a patient after a motor vehicle collision shows crescentic high-density fluid collection around the left kidney. Note the well-defined outer margin

Gambar 6. Kidney trauma. Grade 1 renal injury, subcapsular hematoma. CT scan of the abdomen with intravenous contrast in a patient after a motor vehicle collision; shows crescentic high-density fluid collection around the left kidney. Note the well-defined outer margin and the mild deformity of the renal parenchyma

Derajat II dan III

Gambar 6. Kidney trauma. Grade 2 renal injury, subcapsular and perinephric hematomas. Contrast-enhanced CT scan of the abdomen on a patient with hematuria after a motor vehicle collision shows an ill-defined fluid collection in the left perinephric space. There is also a subcapsular hematoma with deformity of the renal parenchyma

Gambar 7 Kidney trauma. Grade 2 renal injury, perinephric hematoma. Contrast-enhanced CT scan of the abdomen on a patient with hematuria after a motor vehicle collision shows an ill-defined fluid collection in the left perinephric space

Gambar 8. Kidney trauma. Grade 3 renal laceration with normal one-shot intravenous pyelogram. CT scan through the kidneys after intravenous contrast on the same patient as in Image 1 shows renal laceration and perinephric hematoma.

Gambar 9 Kidney trauma. Grade 2 renal laceration. Contrast-enhanced CT scan of the abdomen after a motor vehicle collision shows a superficial (less than 1 cm deep) renal parenchymal defect with a large perinephric hematoma

Gambar 10. Kidney trauma. Grade 2 renal laceration. Delayed image shows no urinary contrast extravasation. Contrast-enhanced CT scan of the abdomen after a motor vehicle collision shows a superficial (<1 cm deep) renal parenchymal defect with a large perinephric hematoma

Gambar 11. Kidney trauma. Grade 3 renal laceration. CT scan of the abdomen after intravenous contrast administration shows irregular nonenhancing renal parenchymal defect with extension greater than 1 cm deep to near the renal pelvis. no urinary contrast extravasation

Gambar 12. Kidney trauma. Grade 3 renal laceration. CT scan of the abdomen after intravenous contrast administration shows irregular nonenhancing renal parenchymal defect with extension greater than 1 cm deep to near the renal pelvis. This delayed image showed no urinary contrast extravasation.

Derajat IV

Gambar13 Kidney trauma. Grade 4-5 renal injury. Lacerations extending to the collecting system. Contrast-enhanced CT scan of the abdomen in a patient with hematuria after a motor vehicle collision shows deep lacerations extending into the collecting system of the right kidney. Extension into the collecting system is confirmed by urinary contrast extravasation on delayed image through the kidney in excretory phase

Gamba14. Kidney trauma. Grade 4-5 renal injury. Lacerations extending to the collecting system. Contrast-enhanced CT scan of the abdomen in a patient with hematuria after a motor vehicle collision shows deep lacerations extending into the collecting system of the right kidney (Image 22). Extension into the collecting system is confirmed by urinary contrast extravasation on this delayed image through the kidney in excretory phase

Gambar 15. Kidney trauma. Grade 4 renal injury segmental infarction. Contrast-enhanced CT scan of the upper abdomen shows a segmental area of nonenhancement in the upper medial left kidney without associated renal laceration

Gambar 16. Kidney trauma. Grade 4 renal injury segmental infarction. Contrast-enhanced CT scan of the upper abdomen in another patient after a motor vehicle collision shows a segmental area of nonenhancement in the upper medial left kidney without associated renal laceration

Derajat V

Gambar 17. Kidney trauma. Grade 5 renal injury. Shattered kidney. Contrastenhanced CT scan of the abdomen in a patient with hematuria and hypotension after a motor vehicle collision shows transection of the right kidney with a large hematoma around and between the 2 halves of the kidney. The 2 halves are both perfused because there were 2 renal arteries Delayed images show urinary contrast extravasation

Gambar 18. Kidney trauma. Grade 5 renal injury. Shattered kidney. Contrastenhanced CT scan of the abdomen in a patient with hematuria and hypotension after a motor vehicle collision shows transection of the right kidney with a large hematoma around and between the 2 halves of the kidney. The 2 halves are both perfused because there were 2 renal arteries. Delayed images show urinary contrast extravasation

Gambar 19 Kidney trauma. Grade 5 renal injury. Shattered kidney. Contrast-enhanced CT scan of the abdomen in a patient with hematuria and hypotension after a motor vehicle collision shows transection of the right kidney with a large hematoma around and between the 2 halves of the kidney. The 2 halves are both perfused because there were 2 renal arteries Delayed images show urinary contrast extravasation

Gambar 20. Kidney trauma. Grade 5 renal injury. Shattered kidney. Contrastenhanced CT scan of the abdomen in a patient with hematuria and hypotension after a motor vehicle collision shows transection of the right kidney with a large hematoma around and between the 2 halves of the kidney. The 2 halves are both perfused because there were 2 renal arteries. Delayed images show urinary contrast extravasation

Gambar 21. Kidney trauma. Grade 5 renal injury. Shattered kidney with renal vein thrombosis (incomplete). CT scan of the abdomen with intravenous contrast administration shattered right kidney and renal vein thrombus extending slightly into the inferior vena cava

Gambar 22. Kidney trauma. Normal ultrasound with grade 5 renal injury. Ultrasound gray-scale image of a patient involved in a motor vehicle collision shows what appears to be a normal right kidney

Gambar 23 Kidney trauma. Grade 5 renal injury. Color Doppler ultrasound of same motor vehicle collision patient as in Image 4 shows no blood flow within the right kidney.

4.Arteriografy

Gambar 24. Kidney trauma. Active vascular contrast extravasation. Catheter angiography during arterial phase on the same patient as in Image 40 shows a small pseudoaneurysm at the lower pole

gambar 25. Kidney trauma. Active vascular contrast extravasation. Catheter angiography during nephrographic phase in the same patient as in Image 41 shows a small pseudoaneurysm at the lower pole

gambar 26. Kidney trauma. Active vascular contrast extravasation. Pseudoaneurysm at the lower pole in the same patient as in Image 42 was embolized by using a coil.

Trauma Ureter
Ureter jalur transportasi dari ginjal ke buli-buli Trauma ureter mengganggu fungsi ginjal
Trauma mengenai pinggang, punggung resiko mengenai ureter ok * Lokasi terlindungi * Ukuran kecil * Mobilitas / fleksibel trauma ureter jarang

Etiologi
Trauma Luar

a. Tajam b. Tumpul Iatrogenik a. Ginekologis b. Pembedahan rektum c. Endoskopi

Pemeriksaan Radiologi
IVP ( Intra Vena Pyelografi )

RPG ( Retro Grade Pyelografi )

USG ( Ultra Sono Grafi ) CT Scan Abdomen

Trauma Vesika Urinaria

Disebabkan : Trauma

- Tumpul - Tajam - Iatrogenik Didaerah pelvis / abdomen bawah/ perineum 60-85 % trauma tumpul 15-40 % trauma tajam

Ruptur vesika urinaria : ke Ekstra peritoneum Intra peritoneum Keduanya Kontusio Vesika Urinaria Sobekan sebagian mkosa vesika urinaria Dinding memar hematom

Pemeriksaan : Sistografi CT scan abdomen - pelvis

Kontusio Vesika Urinaria Normal Tear Drop Mudah sembuh

Ruptur Vesika Urinaria Terlihat ekstravasasi kontras - ekstra peritonial - intra peritonial Dengan CT Scan dpt juga mengevaluasi organ lain

Pear shaped appearance

TRAUMA URETRA
Uretra laki-laki lebih panjang dari wanita Dihubungkan dgn trauma daerah pelvis yg cukup

berat

Etiologi Trauma tumpul Trauma tembus Iatrogenik

Anatomi Uretra posterior * uretra prostatika * uretra membranosa Uretra anterior 3 segmen : * pars bulosa * pars pendulans * pars glanularis sampai ke meatus uretra externa

Diagnosa
Berdasarkan gejala klinik Pemeriksaan penunjang radiologi

RUG ( Retrograde Uretrografi ) Klasifikasi trauma uretra Hasil RUG Klasifikasi Gold Man yaitu : Berdasarkan Kerusakan Anatomi

Ada 5 tipe Tipe 1

. Ruptur ligamentum puboprostatika . Prostate bergeser ke posterior . Uretra tetap intak . Tdk ada extra vasasi zat kontras

Tipe 2
Trauma uretra posterior & diafragma

urogenital Terlihat extravasasi kontras dlm pelvis extra peritoneal Zat kontras tdk ada dalam perineum

Tipe 3
Tipe yang sering Kerusakan meluas Terlihat extravasasi kontras pada rongga pelvis

extra peritoneal dan perineum

Tipe 4
Terjadi dekat buli-buli meluas ke uretra proximal
Extravasasi kontras pada pelvis extra peritoneal &

sekitar proximal uretra Dapat merusak sfingter uretra interna

Tipe 5
Terjadi di uretra anterior
Terlihat extravasasi kontras

bagian inferior diafragma urogenital