upper gu trauma
TRANSCRIPT
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