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Genitourina

ry Trauma

SKDI 3B
Renal Trauma

Epidemiology:
Most common among genitourinary trauma

1-5% of all trauma

Mechanism:
Blunt trauma (motor car accidents, assaults, falls,
contact sports)
Penetrating trauma (stabs, high velovity gunshots)

Blast effect (low velocity gunshots)


Renal Trauma
Presentation

Hematuria (gross or microscopic)


Microscopic = 5 RBCs/HPF
May be absent

Shock (hypotension, tachycardia, oliguria)

Flank bruising/mass

Flank pain/tenderness
Renal Trauma
Indications for Imaging

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 suspicion of renal
injury based on Hx, Px and AXR
Rapid deceleration injury
Lower rib #
Transverse process #
Loss of psoas shadow
Renal Trauma
Options for Imaging

Consider the need for both anatomic and functional information


IVP - Single-shot intra-op

U/S - Confirm 2 kidneys

Angiography - Used for embolization

These modalities have a limited role and have been essentially


replaced by CT scan
Renal Trauma
CT Scan

Provides valuable anatomic and functional information

Provides the most definitive staging information

Provides information on associated injuries

Imaging modality of choice for renal trauma


Renal Trauma
Classification

AAST
Pediatric Renal Trauma
Considerations

Occupies proportionately larger space

Less perirenal and subcutaneous fat

Renal capsule, Gerotas fascia and perirenal fat less


developed (? less fixation)
Vascular pedicle more susceptible to shearing forces

Higher catecholamine output after trauma


Pediatric Renal Trauma
Summary

Shock not a useful parameter


Hematuria may not be present ~10%
High index of suspicion based on mechanism
Liberal use of imaging studies
Renal Trauma
Non-operative Management

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, CBC
Renal Trauma
Indications for Surgical Exploration

ABSOLUTE RELATIVE
Persistent renal bleeding Penetrating injuries
with hemodynamic
instability Extensive urine
extravasation
Expanding perirenal Grade 5 injury
hematoma Shattered kidney
Pedicle injury

Pulsatile perirenal Non-viable tissue


hematoma (>20%)
Arterial injury (main
or segmental)
Bladder Trauma
General Considerations

Relatively uncommon

Often in association with multi-system organ injury


Significant mortality rate (10-20%)
Have high index of suspicion of urethral disruption
injury
Bladder more susceptible to injury when full
Bladder Trauma
Etiology

Blunt

Penetrating

Iatrogenic

Spontaneous rupture
Bladder Trauma
Etiology

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 injuries
Bladder Trauma
Etiology

IATROGENIC
Open or laparoscopic pelvic surgery
Gynecologic, vascular, urologic or general surgery

SPONTANEOUS RUPTURE

Underlying pathology
Cancer, obstruction, XRT, TB, sensory neurologic deficit
Bladder Trauma
Presentation

Hematuria
95% blunt injuries have gross hematuria

Inability to void

Abdominal pain

Abdominal bruising

Pelvic mass

Peritoneal signs

Shock
Bladder Trauma
Imaging

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 organs
Bladder Trauma
Practical Classification

Contusion
Most common
Often diagnosis of exclusion

Laceration/rupture
Extraperitoneal
vs. This is what we really need to know
Intraperitoneal
Bladder Trauma
Management

GENERAL PRINCIPLES
ABCs

Establish urinary drainage/diversion

Antibiotics

CONTUSION
No specific therapy required
Bladder Trauma
Management

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 ruptures
Bladder Trauma
Management

INTRAPERITONEAL RUPTURE
Surgical repair
Midline laparotomy/cystotomy
Multi-layer closure of bladder injury
Bladder drainage
Foley catheter suprapubic catheter
Perivesical drain
Bladder Trauma
Complications

Intraperitoneal
Urinary frequency
Shock
Peritonitis
Azotemia

Extraperitoneal
Shock
Pelvic abscess
INJURIES Of THE URETHRA

Urethral injuries are uncommon and


occur most often in men, usually
associated with pelvic fractures or
straddle-type falls.
Various parts of the urethra may be
lacerated, transected, or contused.
Management varies according to the
level of injury.
The urethra can be separated into 2
broad anatomic divisions: the
posterior urethra, consisting of the
prostatic and membranous portions,
and the anterior urethra, consisting of
the bulbous and pendulous portions
Clinical Findings
Symptoms:

Patients usually complain of lower abdominal pain and inability to


urinate. A history of crushing injury to the pelvis is usually obtained.

Signs:

Blood at the urethral meatus is the single most important sign of


urethral injury (Urethroragia).

Suprapubic tenderness and the presence of pelvic fracture are noted


on physical examination.

A large developing pelvic hematoma may be palpated.

Perineal or suprapubic contusions are often noted.

Rectal examination may reveal a large pelvic hematoma with the


prostate displaced superiorly.
Clinical Findings
Laboratory Findings:

Anemia due to hemorrhage may be


noted.

Urine usually cannot be obtained


initially, since the patient should not
void and catheterization should not
be attempted.
Clinical Findings

Instrumental Examination:

The only instrumentation involved


should be for urethrography.
Catheterization or urethroscopy
should not be done, because
these procedures pose an
increased risk of hematoma,
infection, and further damage to
partial urethral disruptions.
X-Ray Findings

Fractures of the bony pelvis are


usually present.

A urethrogram (using 20-30 ml


of watersoluble contrast
material) shows the site of
extravasation.

Ordinarily, there is free


extravasation of contrast
material into the perivesical
space.

Incomplete
prostatomembranous disruption
is seen as minor extravasation,
with a portion of contrast
material passing into the
prostatic urethra and bladder.
X-Ray Findings
Treatment

Conservative therapy is effective


for patients with recent
nonpenetrating damage of
urethra: rest, cool compresses,
and antibiotics.

Within 7-8 days after trauma


thermal procedures and
resorption agents are prescribed.

Shock and hemorrhage should be


treated.
Treatment
Surgical Measures:
Urethral catheterization should
be avoided.
Initial management should
consist of suprapubic
cystostomy to provide urinary
drainage.
A midline lower abdominal
incision should be made, care
being taken to avoid the large
pelvic hematoma.
The bladder should be opened
and carefully inspected for
lacerations. If a laceration is
present, the bladder should be
closed with absorbable suture
material and a cystostomy tube
inserted for urinary drainage.
The suprapubic cystostomy is
maintained in place for about 3
months. This allows resolution of
Treatment
Urethral reconstruction
-Reconstruction of the urethra
after prostatic disruption can
be undertaken within 3 months.
Before reconstruction, a
combined cystogram and
urethrogram should be done to
determine the exact length of
the resulting urethral stricture.
The preferred approach is a
single-stage reconstruction of
the urethral rupture defect with
direct excision of the strictured
area and anastomosis of the
bulbous urethra directly to the
apex of the prostate.
A 16F silicone urethral catheter
should be left in place along
with a suprapubic cystostomy.
Catheters are removed within a
Complications
Stricture, impotence, and incontinence as complications of
prostatomembranous disruption.

Stricture following primary repair and anastomosis occurs in about


one-half of cases. If the preferred suprapubic cystostomy approach
with delayed repair is used, the incidence of stricture can be reduced
to about 5%.

The incidence of impotence after primary repair is 30-80% (mean,


about 50%). Incontinence in primary reanastomosis is noted in one-
third of patients.

Delayed reconstruction reduces the incidence to less than 5%.