Urogenital Traumas PDF

Urogenital traumas UĞUR BOYLU, M.D. Professor of Urology Istinye University, Faculty of Medicine, Department of Urology Liv Hospital Ulus, Istanbul  Urogenital Trauma Three to 10% of trauma patients have GU involvement; 10-15% of t...

Urogenital traumas UĞUR BOYLU, M.D. Professor of Urology Istinye University, Faculty of Medicine, Department of Urology Liv Hospital Ulus, Istanbul  Urogenital Trauma Three to 10% of trauma patients have GU involvement; 10-15% of trauma patients with abdominal injuries have GU involvement. ØRenal & Ureteral Injury ØBladder Injury ØUrethral Injury ØInjuries of the external genitalia Renal Injury  Renal Injury ØRenal injuries constitute 45% of all GU injuries; ØMost renal injuries (80%) are minor and do not require surgical intervention; ØRenal trauma can happen in both blunt or penetrating trauma; ØRenal injuries are most commonly from motor vehicle accidents (MVAs); Renal Injury Scale  Renal Injury Physical examination: ØFlank ecchymosis or mass indicates a retroperitoneal process but is not specific to renal injuries and rarely occurs acutely. – The most important indicator of renal trauma is gross or microscopic hematuria. – The absence of hematuria, although rare, does not exclude renal injury because it is absent in 5% of patients.  Renal Injury Radiographic Staging ØIVP - double dose ØCT Scan - best method of staging - radiographic study of choice ØUltrasound ØAngiography - used for suspected renovascular injury CT Staging for Renal Injury Right renal stab wound (Grade IV) Left renal laceration Management of Renal Injury Surgical Management for Renal Injury Ureteral Injury  Ureteral Injury ØUreteral injuries after external violence are rare, occurring in less than 4% of cases of penetrating trauma and less than 1% cases of blunt trauma. ØUreteral injuries after external violence, unlike renal injuries, are difficult to detect with the usual array of diagnostic tools. Ureteral Injury Excretory urography demonstrating extravasation in the upper right ureter consequent to stab wound (Arrow) Surgical Management for Ureteral Injury  Bladder Injury ØBladder injuries classified into contusions, extraperitoneal and intraperitoneal ruptures ; Intraperitoneal (20%) Rupture Extraperitoneal (80%) A full bladder is more likely to become injured than an empty one.  Bladder Injury Ømostly occur in blunt trauma. Eighty-five percent of these injuries occur with pelvic fractures; Ø15% occur with penetrating trauma and blunt mechanism without a pelvic fracture (ie, full bladder blowout). Øgross hematuria in the trauma setting requires imaging of both upper and lower urinary tract Bladder Injury  Diagnosis Cystogram and CT are helpful diagnostic tools. Cystogram (left) shows extraperitoneal bladder rupture with extravasation into scrotum. CT(right) reveals intraperitoneal bladder rupture with contrast material surrounding bowel loops Surgical Mangement of Bladder Rupture Urethra Injury  Urethra Injury ØAlmost exclusively in male ØMost common in straddle injure ØSignificant morbidity – Stricture – Incontinence – Impotence ØFoley catheter implication  Urethra Injury Posterior Urethra- Anterior Urethra- Ø Gross hematuria in 98% Ø More common than Ø Inability to void posterior Ø Direct trauma Ø Blood at urethral meatus Ø Usually NO pelvic injury Ø Pelvic / suprapubic Ø Blood at meatus tenderness Ø Unable to micturate Ø Penile / scrotal / perineal Ø Penile/Scrotal/Perineal hematoma – Contusion Ø Boggy / high-riding – Hematoma prostate/ ill-defined mass on rectal examination. – Fluid collection  Urethra Injury High Riding Prostate on DRE EXTRAVASATION OF URINE  Diagnosis Urethrogram is the best diagnostic tool- Urethrogram  Urethrogram Contrast extravasation + Contrast in bladder PARTIAL Tear Contrast extravasation only COMPLETE Tear Urethrogram retrograde urethrography via meatus Extravasation of contrast medium with the “missing” bladder indicates a complete tear of the urethra Management of Urethral Injury ØPartial tear – careful passage of 12-14 Fr. Foley. – If any resistance: Urology ØComplete tear: – Urology + suprapubic cath. ØIf Foley already there and suspect tear: – LEAVE FOLEY IN PLACE Initial urethral repair is not recommended because of risk of hemorrhage, impotence, and infection of pelvic hematoma. Management of Urethral Injury Surgical Repair Bank’s Method  Injuries of the external genitalia ØPenis – Penetrating, skin avulsion and amputation repaired surgically – “fracture” repaired and drained surgically ØScrotum/testes – Hematocele and contusion (mild) or rupture (severe, needs exploration) – Penetrating injuries need exploration  Injuries of the external genitalia scrotal hematoma Penile fracture after straddle injure