Topic Review Genitourinary Trauma Renal injury l GU
- Slides: 40
Topic Review : Genitourinary Trauma
Renal injury l GU tract - 10% of polytrauma patients l Renal injury – most common l blunt / penetrating trauma l Hematuria – best indicator but not always seen l Microscopic hematuria c shock – significant renal injury
Classification
Staging l Imaging modality contrast-enhanced CT spiral CT – rapid but disadvantaged US – more developing IVP – replaced by CT
Flowsheet
Management l Nonoperative -98%, even penetrating trauma; 55% of stab wound, 24% of gunshot wound Mc. Aninch et al, J Urol, 1991 -Hospitalization & Bed rest -Close F/U
Maagement l Operative: nephrectomy, renal exploration - Absolute indication persistent renal bleeding, expanding perirenal hematoma, pulsatile perirenal hematoma - Relative indication urinary extravasation, nonviable tissue, delayed diagnosis of arterial injury, segmental arterial injury, and incomplete staging
Management l Operative Relative indication - Extravasation alone c GIV injuy: 87% conservatively - 20%> nonviable tissue: questionable - Segmental artery injury c laceration : operatively - Incomplete staging
Management l Renal exploration early vascular control – before opening Gerota’s fascia
Management l Renal reconstruction
Management Main renal artery trombosis Reovascular injury • < 8 hr • Replacemet graft • Enovascular stent- only 1 case • Nephrectomy – critical, multiple injury
Ureteral injury l Etiology -External trauma: rare -Open Surgical Injury: hysterectomy (54%), colorectal surgery (14%), pelvic surgery (8%), abdominal vascular surgery (6%) St. lezin, urology, 1991 vascular surgery: benign course hysterectomy&colorectal surgery: complicatable -Laparoscopic injury: mainly OBGY op -Ureteroscopic injury
Ureteral injury l Diagnosis - Hematuria - Intraop recognition - Excretory urogaphy - CT - RGP/AGP
Ureteral injury l Management -External trauma 1. contusion: minor -> ureteral stentin major & large -> ureteoureterostomy (ureteral vascular problem) 2. upper ureteral injury: ureteroueterostomy, ileal interposition
Ureteral injury 3. Mid ureteral injury Ureteroureterostomy(Transureterosto my) 4. Lower ureteral injury ureteroneocystostomy, psoas hitch, Boari flap
Ureteral injury
Ureteral injury End-to-end Debridement of dead tissue Sparing adventitia Spatulation Watertight D-J stent
Ureteral injury Psoas hitch Boari flap
Ureteral injury - Sugical injury 1. Ligation: removal of ligation & ureteral stent or ureterostomy(viability ) 2. Transection #Immediate recognition mainly same as external trauma in aortic surgery: controversial nephrectomy vs ureteoureterostomy
Ureteral injury # delayed recognition (post-op: 3 -30 d) Sign&Sx: fever, leukocytosis, generalized peritoneal signs Repair: controversial ureteral stenting -only 20 -50%, Max 73% ultimate success, at least 6 wks laparoscopic injury: less successful Open repair- immidiate vs delayed (several month) retrograde ureteral stenting fail-> nephrostomy and anterograde stenting Mc. Aninh et al
Ureteral injury -Ureteroscopic Injury avulsion ; treat same as open/lapa injuy perforation; ureteral stenting
Bladder injury < 2% of abdominal injuries requiring op c urethral rupture (10 -29%) 6 -10% of pelvic bone fx, 83 -100% of bladde injury associated c pelvic bone fx. Cass et al, J Urol, 1984 l Etiology -Blunt injury -Penetrating injury
Bladder injury l Diagnosis -Cystography extrapeitoneal intraperitoneal
Bladder injury - CT cystography
Bladder injury l Management - Contusion: no specific therapy - Extraperitoneal injury. mainly catheter drainage only. bone fragment, open pelvic fx. , rectal perforation, catheter obstruction by clot -> open repair Cass et al, Urology, 1989 Kotkin et al, J Trauma, 199. laparotomy, orthopedic open reduction -> open repair
Bladder injury -Intraperitoneal injury 25% of all bladder injury, 12% combined with extraperitoneal injury -> open repair c two-layer closure perivesical drainage, suprapubic&urethral catheter Reason) much larger than cystography persistent urinary leakage peritonitis
Bladder injury l Post injury management Antibiotics F/U cystography extraperitoneal rupture c conservative management: 10 -14 d, if not healed 21 d open repair: 7 -10 d
Urethral injury 1. Posterior urethra Pelvic Fx. : 4 -14% / shear injury B: below prostatic apex C: membranous/ bulbous
Urethral injury l Diagnosis blood at urethral meatus, inability of voiding, palpably full bladder, peirneal hematoma - Urethrography
Urethral injury partial rupture complete rupture
Urethral injury l Initial management -Primary realignment: partial/complete original: open -> indirect/endoscopic stenting Elliot, J Urol, 1997 + suprapubic cystostomy for 3 -6 wks -Suprapubic cystostomy: if fails
Urethral injury l Delayed reconstruction 3 M: scar tissue -> stable, mature Imaging study: cystogram+RGU -Endoscopic reconstruction CIx: defect < 1 cm or significant dislocation -Surgical reconstruction perineal approach / pubotomy / staged: extensive stricture, previous failed urethroplasty(no available penile skin), infected
Urethral injury
Urethral injury Complications - Impotence: 13 -30% - Incontinence: 2 -4% Corriere et al, J Trauma, 1994 open bladder neck > closed bladder neck (53%) Iselin at al, J Urol, 1999 - Stricture l after posterior reconstruction, 12 -15% -> first, endoscopic management
Urethral injury 2. Anterior urethra Straddle/penetrating injury -Initial management Catheter realignment/suprapubic cystostomy -Delayed reconstruction: anastomosis -Complication Impotence / stricture (<5% after anastomosis)
External genitalia injury 1. Penis -Amputation: replantation before 24 hr Revascularization of doral a. is sufficient -Penile Fx. (rupture of corpus cavernosum) Pex: Penile swelling, ecchymosis Hx: popping sound, pain, immediate detumescense Cavernosography(sensitive), US, MRI
External genitalia injury Tx: Immediate repair / conservative management (prolonged adm, complication)
External genitalia injury 2. Testis -Imaging study US: must be adjunct to Pex Intratunical 1 wks later
External genitalia injury Ruptered tunica albuginea
External genitalia injury - Management. Surgical repair / exploration orchiectomy rate: delayed op 21% immidiate op 6% Cass et al, Urology, 1991. Nonoperative Insignificant scrotal injury much pain, longer hospitalization intratesticular hematoma: 40% infection/necrosis
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