urological trauma. renal trauma renal trauma occurs in approximately 1-5% of all traumas. renal...

UROLOGICAL UROLOGICAL

TRAUMATRAUMA

RENAL TRAUMARENAL TRAUMA

Renal trauma occurs in approximately 1-Renal trauma occurs in approximately 1-5% of all traumas.5% of all traumas.

Renal injuries are the most common Renal injuries are the most common injuries of the urinary system.injuries of the urinary system.

Blunt trauma directly to the abdomen, Blunt trauma directly to the abdomen, flank, or back is the most common flank, or back is the most common mechanism, accounting for 80-85% of all mechanism, accounting for 80-85% of all renal injuries. renal injuries.

EthiologyEthiology

Trauma may result from motor Trauma may result from motor vehicle accidents, fights, falls, vehicle accidents, fights, falls, and contact sports. and contact sports.

Fractured ribs and transverse Fractured ribs and transverse vertebral processes may vertebral processes may penetrate the renal penetrate the renal parenchyma or vasculature.parenchyma or vasculature.

Gun-shot and knife wounds Gun-shot and knife wounds cause most penetrating injuries cause most penetrating injuries to the kidney.to the kidney.

ClassificationClassification

ClassificationClassification Minor renal trauma Minor renal trauma

Major renal trauma Major renal trauma (15% of cases)(15% of cases)


Vascular injury Vascular injury (about 1% (about 1% of all blunt trauma cases)of all blunt trauma cases)

Vascular injury of the renal Vascular injury of the renal pedicle is rare but may occur, pedicle is rare but may occur, usually from blunt trauma.usually from blunt trauma.

Clinical FindingsClinical Findings

The clinic of the closed damage of The clinic of the closed damage of kidney depends on its degree.kidney depends on its degree.

Each kind of trauma is Each kind of trauma is accompanied by characteristic accompanied by characteristic manifestations and general signs, manifestations and general signs, which are pain and intumescence in which are pain and intumescence in lumbar region, haematuria. lumbar region, haematuria.

SignsSigns

• Shock symptoms

• Flank ecchimosis, edema

• Pain

• Hematuria (mikro-, gross), bladder tamponade

• Oligoanuria, Subileus


SymptomsSymptoms:: Pain in lumbar region on the Pain in lumbar region on the

side of damage is observed in side of damage is observed in 80- 95 % of cases of isolated 80- 95 % of cases of isolated traumas of kidney and in 10-20 traumas of kidney and in 10-20 % of combined injuries. It is dull % of combined injuries. It is dull or acute with irradiation in or acute with irradiation in inguinal region or external inguinal region or external sexual organs.sexual organs.

DiagnosticsDiagnostics

Laboratory FindingsLaboratory Findings::

Microscopic or gross hematuria is usually Microscopic or gross hematuria is usually present. present.

The hematocrit may be normal initially, The hematocrit may be normal initially, but a drop may be found when serial but a drop may be found when serial studies are done. Persistent bleeding may studies are done. Persistent bleeding may necessitate operation.necessitate operation.

Diagnostics: Diagnostics: ChromocystoscopiaChromocystoscopia

Chromocystoscopy, if possible, also Chromocystoscopy, if possible, also helps to establish the correct diagnosis.helps to establish the correct diagnosis.

This method of research sometimes This method of research sometimes allows to find a location of bleeding allows to find a location of bleeding (that it is very important in case of (that it is very important in case of combined trauma), to analyse functions combined trauma), to analyse functions of damaged and opposite kidney, state of damaged and opposite kidney, state of urinary bladder wall.of urinary bladder wall.

X-Ray FindingsX-Ray Findings

Observing radiographyObserving radiography (KUB): (KUB): tthe method allows to find he method allows to find damage of bones, to suspect damage of bones, to suspect presence of retroperitoneal presence of retroperitoneal hematoma (contours of kidney hematoma (contours of kidney and lumbar muscles are absent).and lumbar muscles are absent).

Excretory urographyExcretory urography gives an gives an opportunity to define the side of opportunity to define the side of damage, anatomical and function damage, anatomical and function status of injured and opposite status of injured and opposite

kidneykidney..


X-ray signs of renal damage are X-ray signs of renal damage are weak and later spreading of X-ray weak and later spreading of X-ray contrast solution in calyces-contrast solution in calyces-bowling systems, bowling systems, subcapsular and retrorenal spreading of X-ray and retrorenal spreading of X-ray contrast, deformation of renal contrast, deformation of renal bowl and calyces. bowl and calyces.

..

• IVP


On angiogramms one can see violation of arterial and On angiogramms one can see violation of arterial and venous circulation attached to marginal injuries, filling of venous circulation attached to marginal injuries, filling of pararenal tissue with X-ray contrast due to injuries of renal pararenal tissue with X-ray contrast due to injuries of renal artery branches.artery branches.

Ultrasonography Ultrasonography

Ultrasound scans can detect renal Ultrasound scans can detect renal lacerations but cannot definitely assess lacerations but cannot definitely assess their depth and extent. In addition, they their depth and extent. In addition, they do not provide functional information. do not provide functional information.

Computed tomography (CT)Computed tomography (CT)

Staging begins with an Staging begins with an abdominal CT scan, the abdominal CT scan, the most direct and effective most direct and effective means of staging renal means of staging renal injuries.injuries.

T R E A T M E N TT R E A T M E N T

Bed regimen is provided within 10-20 day.Bed regimen is provided within 10-20 day.

Measures to stop bleeding (administration of Measures to stop bleeding (administration of haemostatic agents, hemo- and haemostatic agents, hemo- and plasmotransfusion), administration of plasmotransfusion), administration of analgetics, antibiotics of a wide spectrum of analgetics, antibiotics of a wide spectrum of action, and also dynamical overseeing by action, and also dynamical overseeing by arterial pressure. arterial pressure.

Antibiotics are used for pyelonephritis Antibiotics are used for pyelonephritis prophylactics.prophylactics.

T R E A T M E N TT R E A T M E N T

Indications to Indications to operative treatmentoperative treatment: :

аа) internal bleedings in case ) internal bleedings in case of isolated renal damage, of isolated renal damage, which are accompanied by an which are accompanied by an anaemia, decrease of arterial anaemia, decrease of arterial pressure, fast pulse;pressure, fast pulse;

b) hematuria within a day b) hematuria within a day with worsening of general with worsening of general state of the patient; state of the patient;

c) hematoma in lumbar c) hematoma in lumbar region, which is slowly region, which is slowly growing; growing;

d) combination of renal d) combination of renal damage and organs of damage and organs of abdominal cavity or thorax.abdominal cavity or thorax.

TREATMENTTREATMENT

The operation should be maximum savings and directed on the The operation should be maximum savings and directed on the decision of two tasks - stopping of bleeding and normalization of decision of two tasks - stopping of bleeding and normalization of urine outflow. urine outflow.

TREATMENTTREATMENT

INJURIES OF THE URINARY BLADDERINJURIES OF THE URINARY BLADDER

Bladder injuries occur most often from external force and are often Bladder injuries occur most often from external force and are often associated with pelvic fractures. (About 15% of all pelvic fractures are associated with pelvic fractures. (About 15% of all pelvic fractures are associated with concomitant bladder or urethral injuries.) associated with concomitant bladder or urethral injuries.)

Iatrogenic injury may result from gynecologic and other extensive Iatrogenic injury may result from gynecologic and other extensive pelvic procedures as well as from hernia repairs and transurethral pelvic procedures as well as from hernia repairs and transurethral operations.operations.


closed and openclosed and open isolated and combinedisolated and combined intraperitoneal, intraperitoneal,

retroperitoneal and mixed. retroperitoneal and mixed.

Bladder injuriesBladder injuries

Blunt trauma in filled bladderBlunt trauma in filled bladder

1. Intraperitoneal

Rising of intravesical pressure

Hydraulic impact

Intraperitoneal bladder rapture (dome,posterior wall)

2. Extraperitoneal


Symptoms:Symptoms:

There is usually a history of lower abdominal trauma.There is usually a history of lower abdominal trauma. Blunt injury is the usual cause. Blunt injury is the usual cause. Patients ordinarily are unable to urinate, but when Patients ordinarily are unable to urinate, but when

spontaneous voiding occurs, gross hematuria is usually spontaneous voiding occurs, gross hematuria is usually present. present.

Most patients complain of pelvic or lower abdominal Most patients complain of pelvic or lower abdominal painpain..


Signs:Signs: Heavy bleeding associated with pelvic fracture Heavy bleeding associated with pelvic fracture

may result in hemorrhagic shock, usually from may result in hemorrhagic shock, usually from venous disruption of pelvic vessels.venous disruption of pelvic vessels.

An acute abdomen indicates intraperitoneal An acute abdomen indicates intraperitoneal bladder rupture. bladder rupture.

A palpable mass in the lower abdomen usually A palpable mass in the lower abdomen usually represents a large pelvic hematoma.represents a large pelvic hematoma.

On rectal examination, landmarks may be On rectal examination, landmarks may be indistinct because of a large pelvic hematoma.indistinct because of a large pelvic hematoma.


Laboratory FindingsLaboratory Findings:: Catheterization usually is required in Catheterization usually is required in

patients with pelvic trauma but not if patients with pelvic trauma but not if bloody urethral discharge is noted. bloody urethral discharge is noted.

When catheterization is done, gross or, When catheterization is done, gross or, less commonly, microscopic hematuria is less commonly, microscopic hematuria is usually present.usually present.


A plain abdominal film A plain abdominal film generally demonstrates pelvic generally demonstrates pelvic fractures. There may be fractures. There may be haziness over the lower haziness over the lower abdomen from blood and abdomen from blood and urine extravasation.urine extravasation.

An intravenous urogram An intravenous urogram should be obtained to should be obtained to establish whether kidney and establish whether kidney and ureteral injuries are present.ureteral injuries are present.


Bladder disruption is shown on Bladder disruption is shown on cystography.cystography.

The sign of retroperitoneal rupture The sign of retroperitoneal rupture is accumulation of X-ray contrast is accumulation of X-ray contrast matter in perivesical fat tissue.matter in perivesical fat tissue.

With intraperitoneal extravasation, With intraperitoneal extravasation, free contrast medium is visualized free contrast medium is visualized in the abdomen, highlighting bowel in the abdomen, highlighting bowel loops.loops.

TreatmentTreatment A.A. Emergency Measures: Emergency Measures: Shock and hemorrhage should Shock and hemorrhage should

be treated.be treated.

B.B. Surgical Measures: Surgical Measures: The bladder should be opened in The bladder should be opened in

the midline and carefully the midline and carefully inspected. After repair, a inspected. After repair, a suprapubic cystostomy tube is suprapubic cystostomy tube is usually left in place to ensure usually left in place to ensure complete urinary drainage and complete urinary drainage and control of bleeding.control of bleeding.

TreatmentTreatment

In a case of retroperitoneal complete In a case of retroperitoneal complete rupture of the bladder it is exposed by rupture of the bladder it is exposed by suprapubic extraperitoneal access suprapubic extraperitoneal access carefully inspected and is juncture by carefully inspected and is juncture by two-row catgut junctures.two-row catgut junctures.

TreatmentTreatment

Intraperitoneal bladder ruptures should Intraperitoneal bladder ruptures should be repaired via a transperitoneal be repaired via a transperitoneal approach after careful transvesical approach after careful transvesical inspection and closure of any other inspection and closure of any other perforations. perforations.

INJURIES Of THE URETHRAINJURIES Of THE URETHRA

Urethral injuries are Urethral injuries are uncommon and occur most uncommon and occur most often in men, usually often in men, usually associated with pelvic associated with pelvic fractures or straddle-type fractures or straddle-type falls.falls.

The urethra can be separated The urethra can be separated

into 2 broad anatomic into 2 broad anatomic divisions: the posterior divisions: the posterior urethra, consisting of the urethra, consisting of the prostatic and membranous prostatic and membranous portions, and the anterior portions, and the anterior urethra, consisting of the urethra, consisting of the bulbous and pendulous bulbous and pendulous portionsportions


Signs:Signs: Blood at the urethral meatus is Blood at the urethral meatus is

the single most important sign of the single most important sign of urethral injury (urethral injury (UrethroragiaUrethroragia).).


Suprapubic tenderness and the presence of pelvic fracture are noted on Suprapubic tenderness and the presence of pelvic fracture are noted on physical examination.physical examination.

A large developing pelvic hematoma may be palpated.A large developing pelvic hematoma may be palpated. Perineal or suprapubic contusions are often noted. Perineal or suprapubic contusions are often noted. Rectal examination may reveal a large pelvic hematoma with the prostate Rectal examination may reveal a large pelvic hematoma with the prostate

displaced superiorly. displaced superiorly.

Clinical Clinical FindingsFindings

Instrumental Examination:Instrumental Examination:

The only instrumentation The only instrumentation involved should be for involved should be for urethrography.urethrography.

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


Fractures of the bony pelvis are usually present.Fractures of the bony pelvis are usually present.

TreatmentTreatment

In case of ischuria instead of a In case of ischuria instead of a high cystotomy it is possible high cystotomy it is possible to perform troacar to perform troacar epicystostomy.epicystostomy.

Shock and hemorrhage should Shock and hemorrhage should

be treatedbe treated..

TreatmentTreatment

Surgical Measures:Surgical Measures:

Urethral catheterization should be Urethral catheterization should be avoided.avoided.

InitialInitial management should consist management should consist of suprapubic cystostomy to provide of suprapubic cystostomy to provide urinary drainage.urinary drainage.

A midline lower abdominal incision A midline lower abdominal incision should be made, care being taken to should be made, care being taken to avoid the large pelvic hematoma. avoid the large pelvic hematoma.

The suprapubic cystostomy is The suprapubic cystostomy is maintained in place for about 3 maintained in place for about 3 months. This allows resolution of the months. This allows resolution of the pelvic hematoma, and the prostate pelvic hematoma, and the prostate and bladder will slowly return to and bladder will slowly return to their anatomic positions.their anatomic positions.

TreatmentTreatment

Urethral Urethral

reconstructionreconstruction - -ReconstructionReconstruction of the of the urethra after prostatic urethra after prostatic disruption can be disruption can be undertaken within 3 undertaken within 3 months.months.

ComplicationsComplications

Stricture, impotence, and incontinence as Stricture, impotence, and incontinence as complications of prostatomembranous complications of prostatomembranous disruption.disruption.

Penis fracturePenis fracture

Tunica albuginea rapture

Penis traumaPenis trauma

ParaphimosisParaphimosis

DD: Epididymitis

acute begining

Doppler sonography

In doubt :

always operation

4-6 hours

Testicle torsion Testicle torsion

Skrotal hematomaSkrotal hematoma

Testicle traumaTesticle trauma

4-6 h time limit

Punction + aspiration from 50 to 200 ml of blood

Injektion of 5 mg Alpha-Sympathomimetics (Effortil)

Winter Shunting fistula

PriapismPriapism

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