in the name of god genitourinary trauma ali ariafar. m.d urology- oncoloy fellowship shiraz...
TRANSCRIPT
IN THE NAME OF GOD
Genitourinary Trauma
Ali Ariafar. M.DUrology- Oncoloy FellowshipShiraz university of medical sciences
Renal Trauma
Three to 10% of trauma patients have GU involvement; 10-15% of trauma patients with abdominal injuries have GU involvement.
In patients with GU trauma, symptoms are nonspecific and may be masked by or attributed to other injuries.
In blunt trauma, history is obtained regarding the time and mechanism of injury, position of the patient, speed of the vehicle, and use of restraints.
In penetrating trauma, knowing the size of the stabbing weapon or the caliber of the gun and the distance from which it was discharged aids assessment..
Renal injuries are the most common injuries of the urinary System( 45% of all GU injuries)
Renal injuries are most commonly from motor vehicle accidents (MVAs).
Renal Trauma
The most important indicator of renal trauma is gross or microscopic hematuria. however the degree of hematuria and the severity of renal injury do not correlate consistently
Blunt trauma is cause 80% of renal injuries among patients with gross hematuria, notable renal trauma is present in 25%
less than 1% of patients with microhematuria have
substantial renal injury The absence of hematuria, although rare, does not
exclude renal injury because it is absent in 5% of patients and 36% renal vascular injury
Renal Trauma Flank ecchymosis or mass indicates a retroperitoneal
process but is not specific to renal injuries and rarely occurs acutely.
Suspect renal injury when fractures of lower ribs and/or spinal processes are observed and/or when a history of sudden deceleration or significant lateral force on the patient exists.
Trajectory of the bullet or penetrating object helps indicate the possibility of renal injury.
Presence of abdominal, visceral, solid organ, or vascular injury indicates renal injury, as these injuries coexist with renal injuries in 34% of patients with blunt trauma and in up to 80% of patients with penetrating trauma.
Renal Trauma Renal Injury ScaleGrade Injury Description I microscopic or gross hematuria, urologic studies
normal subcapsular hematoma, non-expanding without parenchymal laceration
II non-expanding perirenal hematoma confined to renal retroperitoneum, or laceration < 1.0 cm parenchymal depth of renal cortex without urinary extravasation
III laceration > 1.0 cm parenchymal depth of renal cortex without
urinary extravasation or collecting system rupture
IV parenchymal laceration extending through the renal cortex, medulla, and collecting system, or main renal artery or vein injury with contained hemorrhage
V completely shattered kidney or avulsion of renal hilum which devascularizing the kidney
Renal Injury Scale
Renal Trauma
Lab Studies:
Complete blood count (CBC) to obtain hematocrit level and platelet count
Prothrombin time (PT) and activated partial thromboplastin time (aPTT) to check for coagulopathy; may be unnecessary in young, otherwise healthy patients
BUN and serum creatinine: Elevation of BUN without elevation in creatinine indicates urine reabsorption.
Urinalysis to diagnose hematuria Blood type and crossmatch
Renal Trauma
Indications for Radiographic Assessment in suspected renal trauma
penetrating trauma to flank or abdomen regardless of the degree of hematuria (microscopic or gross)
in all adult patients with blunt abdominal trauma with gross hematuria
in all adult patients with blunt abdominal trauma with microscopic hematuria and associated shock (<90 mm Hg)
deceleration injuries from history major intra-abdominal injuries with
microhematuria pediatric flank or abdominal trauma with any
degree of hematuria
Renal Trauma
Radiographic Staging IVP - double dose CT Scan - best method of staging -
radiographic study of choice Ultrasound Angiography - used for suspected
renovascular injury
Renal Trauma Most renal injuries (80%) are minor and do
not require surgical intervention Absolute Indications for Surgery Signs and symptoms of persistent bleeding
Unstable vital signs Decreasing hemoglobin Expanding flank mass
Relative Indications for Surgery Urinary Extravasation Renovascular injury Incomplete staging Nonviable tissue
Renal Trauma
Complications Persistent urinary extravasation Delayed renal bleeding Perinephric abscess Hypertension Arteriovenous fistula Hydronephrosis
Grad 1
Grade 2
Grade 3
Grade 4
Grade 4-5
Grade 5(UP avultion)
Grade 5(shattered kidney)
Grade 5(devascularization)
Grade 5(devascularization)
Surgery
Ureteral trauma Ureteral injury is rare but may occur, usually during
the course of a difficult pelvic surgical procedure or as a result of stab or gunshot wounds
Occur in less than 4% of penetrating trauma and less than 1% of blunt trauma
Hystrectomy was responsible for the majority of surgical injury(54%) followed by colorectal surgury (14%)
Ureteral Injury
Diagnosis Hematuria (25-45% have no microhematuria)
fever flank pain nausea and vomiting acute peritonitis Paralytic ileus Watery discharge from the wound or
vagina
Ureteral Injury
Imaging No ideal study
IVP—non-diagnostic in 33-100% Finding subtle on both IVP and CT Delayed function Ureteral dilation/deviation
Retrograde—only to delineate extent of injury
Antegrade—only if retrograde not possible
Ureteral Injury Treatmen
LOWER URETERAL INJURIES MIDURETERAL INJURIES UPPER URETERAL INJURIES
Complications Stricture Urinoma Pyelonephritis fistula formation. peritonitis
Bladder Trauma
Bladder injuries mostly occur in blunt trauma. Eighty-five percent of these injuries occur with pelvic fractures; 15% occur with penetrating trauma and blunt mechanism without a pelvic fracture (ie, full bladder blowout).
Obstetric and gynecologic complications are the most common etiology of bladder injuries during open surgery
Bladder Trauma
Bladder injuries: classified into contusions, extraperitoneal and
intraperitoneal ruptures
10% of patients with pelvic fractures will have a bladder injury
>80% of patients with bladder injuries have an associated pelvic fracture
gross hematuria in the trauma setting requires imaging of both upper and lower urinary tract
CLINICAL INDICATORS OF BLADDER INJURY
Suprapubic pain or tenderness Inability to void or low urine output Clots in urin Abdominal distention or ileus Free intraperitoneal fluid on CT or
ultrasound examination
Indication for cystography
Gross hematuria with pelvic fracture(29% have bladder rupture)
penetrating injuries of the buttock, pelvis, or lower abdomen with any degree of hematuria
cystography is nearly 100% accurate for bladder injury
Cystogram finding
Extraperitoneal rupture: Dense, flame-shaped collection of contrast material in the pelvis
Intraperitoneal rupture: contrast material surrounding loops of bowel
Extrapritoneal rupture of bladder
Intrapritoneal rupture of bladder
Bladder Trauma Intraperitoneal ruptures usually associated with full
bladder and seatbelt injury or sudden blunt injury to lower abdomen
Bladder injury occurs at dome of bladder where there is peritoneal covering
All intra-peritoneal bladder injures should be repaired operatively
Extraperitoneal injuries usually associated with pelvic fractures - mechanism of action is secondary to shearing forces or bony spicules penetrating bladder
Most extraperitoneal bladder injuries may be treated with catheter drainage alone however relative indications for surgery include:
Continued bleeding Presence of bone in bladder Concomitant laparotomy
Complications Unrecognized bladder injuries may
manifest as acidosis, azotemia, fever and sepsis, low urine output, peritonitis, ileus, urinary ascites, or respiratory difficulties.
Unrecognized bladder neck, vaginal, and rectal injury associated with the bladder rupture can result in incontinence, fistula, stricture, and difficult delayed major reconstruction.
Severe pelvic fractures may cause a transient or permanent neurologic injury and result in voiding difficulties despite an adequate bladder repair.
Urethral TraumaUrethral Injuries: divided into posterior and anterior urethral injuries
anterior urethral injuries caused by blunt (straddle injury
to perineum) or penetrating injury - usually have scrotal penile swelling and blood at the meatus
posterior urethral injuries occur in 2-5% of patients with pelvic fractures
blood at the meatus is the best sign in both injuries however, must have high index of suspicion
in posterior urethral injuries may also get inability to void, a high riding prostate, scrotal swelling and ecchymosis, and "butter fly" bruising in perineum
in suspected urethral injury - must do retrograde urethrogram prior to inserting catheter
Urethral Trauma posterior urethral injuries occur
commonly at bulbomembranous junction
penetrating anterior urethral injuries usually best dealt with debridement and possible immediate reconstruction
blunt anterior urethral injuries usually best dealt with catheter stenting +/- suprapubic tube insertion
Urethral Trauma
Imaging Studies: Plain radiograph of the pelvis to assess presence
and extent of bony injury Retrograde urethrogram
This is indicated prior to the insertion of a Foley catheter when urethral injury is suspected.
Retrograde cystogram 250 cc are introduced through the Foley
catheter. If the patient reports no discomfort, another
150 cc are introduced, and the catheter is clamped.
Urethral Trauma
Urethral Trauma
Management of urethral injuries - Related to type of injury sustained, but basic principles apply Drain the bladder with a suprapubic catheter
percutaneously or open to prevent further extravasation.
Initial urethral repair is not recommended because of risk of hemorrhage, impotence, and infection of pelvic hematoma.
Commence definitive management of urethral injuries after stabilizing the patient and attending to associated injuries, if present.
Repair can be performed as immediate primary closure, delayed primary closure (10-14 d), or late primary closure (>3 mo).
Complication
Stricture incontinence Erectile dysfunction
Penile Trauma
Penis fracture Penis amputation Gun-shot Animal and Human
Bites
Penis Fracture Mechanism buckling injury to rigid penis The tunica albuginea is a bilaminar
structure (inner circular, outer longitudinal)
The outer layer determines the strength and thickness of the tunica
When the erect penis bends abnormally, the abrupt increase in intracavernosal pressure cause transverse laceration
Etiology
Sexual intercourse(94%) Masturbation Rolling over or falling on to the erect
penis Self-inflicted fractures during
masturbation (69%in Kermanshah)
Diagnosis and sign/symptom
The diagnosis of penile fracture is made by history and physical examination
Popping sound, followed by pain, rapid detumescence, and discoloration and swelling of the penile shaft.
Eggplant deformity (Buck's fascia remains intact)
Deviates to the side opposite the tunical tear.
“Rolling sign” firm, mobile, discrete, tender swelling over which the penile skin can be rolled
Imaging
Cavernosography urethrography Ultrasonography MRI (highly accurate )
False fracture
Rupture of the dorsal penile artery or vein
Tear of suspensory ligament
Penis fracture
Penis fracture
Outcome and Complications.
Immediate surgical reconstruction results in faster recovery, decreased morbidity, lower complication rates, and lower incidence of long-term penile curvature
Conservative management of penile fracture results in penile curvature in more than 10% of patients, abscess or debilitating plaques in 25% to 30%, and significantly longer hospitalization times and recovery
Gunshot Wounds.
77% to 80% of victims have significant associated injuries
Urethral injuries have been reported in 15% to 50%
Treatment principles include immediate exploration, copious irrigation, excision of foreign matter, antibiotic prophylaxis, and surgical closure.
Animal and Human Bites
Initial management of dog bites includes copious irrigation, débridement, and immediate primary closure along with prophylactic broad-spectrum antibiotics(penicillin V-chloramphenicol)
Human bites produce potentially contaminated wounds that often should not be closed primarily
Tetanus and rabies immunizations
Amputation rare, usually the result of genital self-mutilation. 65 to 87% of patients performing genital self-
mutilation are psychotic microsurgical repair achieve good results. Successful reimplantation is possible after 16 hours
of cold ischemia time or 6 hours of warm ischemia Adequate erectile function(more than 50%) is
possible with both technique, complications such as urethral strictures, skin loss,
and sensory abnormalities are all much higher without microvascular repair. Normal penile sensation returns in 0% to 10% of patients after macroscopic replantation whereas sensation is present in more than 80% of microscopic replantations
Penile amputation in the initial stage of replantation.
Partial penile amputation.
Partial penile amputation.
Repair of partial penile amputation
Testis trauma
blunt trauma (about 75% of cases) Penetrating injuries(25%) 1.5% of blunt testis injury and 30%
of penetrating scrotal trauma involves both gonads
Most penetrating scrotal trauma (72% to 83%) is associated with nongenitourinary injuries
Etiology The most common cause of blunt
testicular trauma is sports injuries The second most common cause of
testicular trauma is a kick to the groin. Less common etiologies include motor vehicle accidents, falls, and straddle injuries.
The most common cause of penetrating testicular injuries is a gunshot wound to the genital area. Other causes include stab wounds, self-mutilation, animal bites (usually dog), and emasculation
Sign -Symptom
exquisite scrotal pain and nausea. Swelling and ecchymosis Scrotal hemorrhage and hematocele tenderness to palpation degree of hematoma does not
correlate with the severity of testis injury
Imaging
Ultrasonography CT MRI
disrupted tunica albuginea intratesticular hematoma
Differential diagnosis of testis rapture
Hematocele without rupture, Torsion of the testis or an appendage
(5% of torsions are precipitated by trauma)
Reactive hydrocele, Hematoma of the epididymis or
spermatic cord Intratesticular hematoma. Dislocation after trauma.
Management MAJOR scrotal injuries: Early
exploration and repair of testis injury is associated with increased testis salvage, reduced convalescence and disability, faster return to normal activities, and preservation of fertility and hormonal function
Minor scrotal injuries: managed with ice, elevation, analgesics, and irrigation and closure in some circumstances
Indication of surgical exploration
tunica albuginea rupture Significant intratesticular
hematomas Significant hematoceles (up to 80%
are due to testis rupture ) Penetrating scrotal injuries
Surgical repair
Complications
Testicular infarction Testicular torsion Testicular or epididymal abscess Infertility Testicular necrosis Testicular atrophy
Outcome Testis salvage rates exceed 90% with
exploration and repair within 3 days of injury versus orchiectomy rates threefold to eightfold higher with conservative management and delayed surgery
Testis salvage rates with conservative management are as low as 33%, with delayed orchiectomy rates between 21% and 55%
Penetrating testis trauma is associated with gonad salvage in only 32% to 65% of cases