upper gu trauma

Genitourinary Trauma10th Jan, 2013

By : Ext. Sirada Chittiwan

Ext. Jaipisut Rattanakajornsak

Introduction

• 10-20% of all injured patients• Kidney : The most common• Life-threatening injuries first

A : airway with cervical spine protectionB : breathingC : circulation and control of external bleedingD : disability or neurological statusE : exposure (undress) and environment

(temperature control)

Content

• Upper Urinary tract traumaRenal injuriesUreteral injuries

• Lower Urinary tract traumaBladder injuriesUrethral injuries

• External Genitalia injuries

Upper Urinary tract

trauma

Renal Injuries

RENAL INJURIES : Etiology

• The most common of all injuries to the GU system

• Blunt trauma 80-85%

– Motor vehicle accidents, fights, falls, contact sports

– Vehicle collision at high speed : rapid deceleration ,

major vascular injury

• Penetrating : Associated abdominal visceral injuries 80%

- Gunshot wounds

- Stab wounds

Mechanism of Renal Injuries

Clinical findings

• Pain : localized to one flank area or over the abdomen

• Gross or microscopic hematuria• Ecchymosis in the flank or upper quadrants of

the abdomen• Lower ribs or transverse process fracture• Palpable mass : large retroperitoneal hematoma

or urinary extravasation• Generalized peritonitis

Classification

American Association for Surgery of Trauma Organ Injury Severity Scale for the Kidneys

Indications for Renal Imaging

• Blunt trauma with gross hematuria• Blunt trauma with microscopic hematuria and

shock (SBP < 90 mmHg anytime)• Penetrating injuries with any degree of hematuria• Pediatric patients (< 16 years)• suspected any possible renal injury (e.g. patients

sustaining blunt trauma from rapid deceleration )

Imaging studies

• Contrast-enhanced CT -- preferred• Single-shot intraoperative excretory urography• Arteriography• Sonography

Imaging Studies : Contrast-Enhanced CT

The preferred imaging study;• Parenchymal lacerations• Extravasation of contrast-enhanced urine • Associated injuries • Degree of retroperitoneal bleeding • Lack of uptake of contrast material in the

parenchyma suggests arterial injury

Findings on CT that suggest Major injury

(1) medial hematoma : suggesting vascular injury

(2) medial urinary extravasation : suggesting renal pelvis or ureteropelvic junction avulsion injury

(3) lack of contrast enhancement of the parenchyma : suggesting arterial injury

Single-shot intraoperative IVP

• Only a single film is taken 10 minutes after intravenous injection (IV push) of 2 mL/kg of contrast material

• If findings are not normal or near normal, the kidney should be explored to complete the staging of the injury and reconstruct any abnormality found

Arteriography

• To define arterial injuries suspected on CT• To localize arterial bleeding that can be controlled

by embolization

Sonography

• Immediate evaluation of injuries• Confirms the presence of two kidneys• Can easily define any retroperitoneal hematoma• Cannot clearly delineate parenchymal lacerations

and vascular or collecting system injuries• Cannot accurately detect urinary extravasation in

acute injuries

MANAGEMENT

• Nonoperative Management • Operative Management

Nonoperative Management : Isolated Renal Injuries

• Approximately 80% to 90% of renal injuries have major associated organ injury

• Blunt trauma can be managed nonoperatively• Patients with grade IV parenchymal lacerations can be

observed expectantly

• Complete bed rest • IV fluid replacement• ATB prophylaxis• Analgesic and Sedation• TT prophylaxis

Operative Management

• Absolute indications– Evidence of persistent renal bleeding– Expanding perirenal hematoma– Pulsatile perirenal hematoma

• Relative indications– Urinary extravasation– Nonviable tissue– Delayed diagnosis of arterial injury– Segmental arterial injury– Incomplete staging

Renal Exploration

Surgical exploration of the acutely injured kidney is best done by

Transabdominal approach

allows complete inspection of

intra-abdominal organs and bowel

ส

Surgical Approach tothe renal vessels and kidney

Renal Reconstruction

Technique for Renorrhaphy

Renovascular Injuries

Indications for Nephrectomy

• Unstable patient, with low body temperature and poor coagulation

• Extensive renal injuries when the patient’s life would be threatened by attempted renal repair

Complications

• Urinoma – internal ureteral stent• Perinephric abscess – percutaneous draingage,

surgical drainage• Delayed renal bleeding

– Usuall occurs within 21 days– Angiography and embolization

• Hypertension

Arterial Hypertension

• Renal vascular injury, leading to stenosis or occlusion of the main renal artery or one of its branches

• Compression of the renal parenchymal with extravasated blood or urine

• Post-trauma arteriovenous fistula

Ureteral Injuries

URETERAL INJURIES : Etiology

• External Trauma (20%)

- After external violence are rare (<1%)

- 10 - 28% have associated renal injuries

- 5% have associated bladder injuries • Surgical Injury (80%)

– Pelvic surgical procedure (M/C: Hysterectomy)– Endoscopic manipulation, etc.

Clinical findings

• Post operative fever• Flank and lower quadrant pain• Paralytic ileus with nausea and vomitting• Peritonitis• Uretervaginal fistula• Ureterocutaneous fistula• Hematuria

American Association for the Surgery of Trauma Organ Injury Severity Scale for the Ureter

Imaging Studies

• Excretory Urography : intraoperative one-shot pyelography

• Computed Tomography - IVP• Retrograde Ureterography • Antegrade Ureterography : If retrograde stent

placement is not possible

Imaging findings

• Excretory urography– Delayed function– Hydronephrosis– Extravasation

• Retrograde ureterography– Demonstrates the exact

site of obstruction or extravasation

Treatment

• Repair when injury occurs– Before 7 days immediate Reexploration and

repair– Delayed diagnosis nephrostomy + repair after

3 months

Goals of ureteral repair– Complete debridement, tension-free spatulated

anastomosis, watertight closure, ureteral stenting, retroperitoneal drainage