TRAUMA UROLOGIC

DR.H.T.FARIZAL FADIL Sp.B

FINACS.FMAS.TRAUMA(K)
FF,0710
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BLADDER TRAUMA

Bladder injury from a motor vehicle collision may occur from direct impact with the car or indirectly from the steering wheel or seatbelt. Deceleration injuries of the urinary bladder usually result from falling from a great height and landing on unyielding ground. Assault to the lower abdomen by a sharp kick or blow may result in a bladder perforation. Penetrating injuries to the bladder usually result from high-velocity gunshots or sharp stab wounds to the suprapubic area.
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Penetrating trauma Obstetric trauma Gynecologic trauma Urologic trauma Orthopedic trauma Idiopathic bladder trauma

Blunt trauma

Frequency Frequency of bladder rupture varies according to the following mechanisms of injury: External trauma (82%) Iatrogenic (14%) Intoxication (2.9%) Spontaneous (<1%)

Traumatic bladder ruptures Of traumatic ruptures, -extraperitoneal bladder perforations account for 50%-71%, intraperitoneal accounts for 25%43%, combined perforations account for 7%-14%.

Associated bowel injuries Among patients with bladder trauma due to a gunshot, the incidence of associated bowel injuries is reportedly as high as 83%. Colon injuries are reported in 33% of patients with stab wounds, and vascular injuries are reportedly as high as 82% in patients with a penetrating trauma (with a 63% mortality rate).
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Gross hematuria after blunt trauma and normal imaging findings Patients presenting with gross hematuria after extreme physical activity (ie, long-distance running)

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Extraperitoneal bladder ruptures Traumatic extraperitoneal ruptures are usually associated with pelvic fractures (89%-100%)

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CT scan of extraperitoneal bladder rupture. The contrast extravasates from the bladder into the prevesical space.

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Intraperitoneal ruptures contrast extravasation into the peritoneal cavity, often outlining loops of bowel, filling paracolic gutters, and pooling under the diaphragm. more common in children because of the relative intra-abdominal position of the bladder. The bladder usually descends into the pelvis by age 20 years.
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Cystogram of intraperitoneal bladder rupture. The contrast enters the intraperitoneal cavity and outlines loops of bowel.

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Cystogram of extraperitoneal bladder rupture. Note the fractured pelvis and contrast extravasation into the space of Retzius.

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Presentation Clinical signs of bladder injury are relatively nonspecifi, a triad of symptoms is often present -gross hematuria, ----suprapubic pain or tenderness, -difficulty or inability to void)

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Indications
Foley catheter CT scanning Cystography

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Contraindications Posterior urethral injury is a specific contraindication to insertion of a urethral Foley catheter. Suspect a posterior urethral injury -if blood is present at the meatus, -in all pelvic fractures, -high-riding prostate is found on digital rectal examination.

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PENILE TRAUMA

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Introduction Traumatic penile injury can be due to multiple factors. Penile fracture, penile amputation, penetrating penile injuries, penile soft tissue injuries are considered urologic emergencies and typically require surgical intervention. The goals of treatment for penile trauma are universal: preservation of penile length, erectile function, and maintenance of the ability to void while standing. Traumatic injury to the penis may concomitantly involve the urethra.1 Urethral injury and repair is beyond the scope of this article but details can be

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Penile fracture Penile fracture is the traumatic rupture of the corpus cavernosum. Traumatic rupture of the penis is relatively uncommon and is considered a urologic emergency. .

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Partial penile amputation.

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Gunshot wound to the penis.

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Etiology Penile fracture In the Western Hemisphere, penile fracture usually occurs during sexual intercourse when the penis slips out of the vagina and strikes the perineum or the pubic symphysis. Other potential causes include industrial accidents, masturbation, gunshot wounds, or any other mechanical trauma that causes forcible breaking of an erect penis

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Pathophysiology The penis is composed of 3 bodies of erectile tissue: the corpus cavernosum (left and right) and the corpus spongiosum. Both corpora cavernosa are contained by the tunica albuginea. All three corpora are surrounded individually by Buck fascia. All three corporal cylinders are capable of considerable enlargement with sanguineous engorgement during normal erection. The corpora cavernosa are composed of sinusoids that fill with arterial blood during erection. The internal pudendal arteries provide the blood supply to the penis and the urethra. Each artery divides into the dorsal penile artery, the cavernosal artery, and the bulbourethral artery. The cavernosal artery supplies the corpus 28 cavernosum

Relevant Anatomy The penis is divided into 3 parts. The root lies under the pubic bone and provides stability when the penis is erect. The body comprises the major portion of the penis and is composed of 2 cavernosal bodies and a corpus spongiosum. The urethra traverses the corpus spongiosum to exit through the meatus. The 2 cavernosal bodies (ie, corpus cavernosa, erectile bodies) produce erections when filled with blood. The glans is the distal expansion of the corpus spongiosum. The loose skin of the prepuce normally covers the glans of an uncircumcised penis.
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Contraindications Contraindications to surgical therapy include intolerance to general anesthesia and a history of penile trauma but completely normal physical examination findings. In patients with polytrauma, lifethreatening injuries must be prioritized; delayed penile repair can be considered when the patient becomes medically stable.6 Patients with penile trauma require fluid resuscitation prior to operative intervention

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Urethral Trauma

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History of the Procedure Most urethral injuries are associated with well-defined events, including major blunt trauma such as caused by motor vehicle collisions or falls. Penetrating injuries in the area of the urethra may also cause urethral trauma. Straddle injuries may cause both short- and long-term problems. Iatrogenic injury to the urethra from traumatic catheter placement, transurethral procedures, or dilation is not uncommon

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Frequency Posterior urethral injuries are most commonly associated with pelvic fracture, with an incidence of 5%10%. With an annual rate of 20 pelvic fractures per 100,000 population, these injuries are not uncommon.1 Anterior urethral injuries are less commonly diagnosed emergently; thus, the actual incidence is difficult to determine.

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Presentation Diagnosis of urethral injuries requires a reasonably high index of suspicion. Urethral injury should be suspected in the setting of pelvic fracture, traumatic catheterization, straddle injuries, any penetrating injury near the urethra.
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Urethrogram demonstrating partial urethral disruption.

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Urethrogram demonstrating complete urethral disruption.

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Contraindications In cases of urethral trauma, patients often have multiple injuries. Immediate urethral repair is relatively contraindicated because life-threatening injuries must be corrected first in any trauma algorithm. Urethral repair should be undertaken after the patient has stabilized, when hemorrhage is less of a concern.
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URETER TRAUMA

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Etiology
While injuries to the ureter can result from external trauma, iatrogenic causes are more common. These are usually associated with abdominopelvic surgery

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Reported intraoperative injuries -----include ligation, -transection, electrocautery, ---------avulsion. secondarily affected during fibrotic or inflammation reactions. ---Iatrogenic injuries are typically isolated and thus tend to present differently from those associated with external violence.

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External trauma The ureter is involved in less than 1% Iatrogenic causes Gynecologic surgery

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Colorectal surgery: -low anterior resection (LAR) and -abdominal perineal resection (APR) -Vascular surgery -Urologic procedures -Other iatrogenic causes

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Most iatrogenic injuries (70%-80%) are diagnosed postoperatively. The presenting signs and symptoms may include -flank pain (36%-90%), -fever and sepsis (10%), -fistula (ureterovaginal and/or ureterocutaneous), urinoma, prolonged ileus, or -renal failure secondary to bilateral obstruction (10%)

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Renal Trauma

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Problem Most renal trauma occurs as a result of blunt trauma. Renal injuries may be generally divided into 3 groups: renal laceration, renal contusion renal vascular injury.

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Renal trauma accounts for approximately 3% of all trauma admissions and as many as 10% of patients who sustain abdominal trauma.
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Etiology The mechanism of injury should alert the clinician to the possibility of renal trauma. The following list is not all-inclusive, but it highlights the major mechanisms that generate renal injuries.
Penetrating (eg, gunshot wounds, stab wounds) Blunt (eg, pedestrian struck, motor vehicle crash, sports, fall) Iatrogenic (eg, endourologic procedures, extracorporeal shock-wave lithotripsy,1 renal biopsy, percutaneous renal procedures) Intraoperative (eg, diagnostic peritoneal lavage2 ) Other (eg, renal transplant rejection, childbirth3 [may cause spontaneous renal lacerations])
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Laboratory Studies Urinalysis Imaging Studies Intravenous pyelogram Computed tomography Angiography Ultrasonography

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