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Urologic trauma •Trauma: defined as the morbid condition of the body produced by external violence. •Renal trauma occurs in approximately 1%– 5% of all traumas Urologic trauma Urgent but usually not emergent • 1. Is the patient well enough to undergo an operation? • 2. Will an operation improve the situation or is a minimally invasive approach or patience a better course of action? • 3. Have you considered possible concomitant pathology or injuries? • 4. Should you involve a general surgeon, internist, or intensivist in the patient’s care? • 5. Would additional imaging be helpful?
10/4/2015 ĐIỀU TRỊ CHẤN THƯƠNG NIỆU PGS Phạm Văn Bùi Urologic trauma •Trauma: defined as the morbid condition of the body produced by external violence •Renal trauma occurs in approximately 1%– 5% of all traumas 10/4/2015 Urologic trauma Urgent but usually not emergent • Is the patient well enough to undergo an operation? • Will an operation improve the situation or is a minimally invasive approach or patience a better course of action? • Have you considered possible concomitant pathology or injuries? • Should you involve a general surgeon, internist, or intensivist in the patient’s care? • Would additional imaging be helpful? Two rules govern the management of urologic trauma • First: in the stable patient all efforts should be made to evaluate and address genitourinary injuries at presentation • Second: in the unstable patient the urologic injuries must be measured alongside other, often more life-threatening injuries; urologic injuries can often be managed without reconstruction or temporized with a drain 10/4/2015 RENAL TRAUMA • Kidney:the most commonly injured genitourinary and abdominal organ, with the male to female ratio being3:1 • Renal trauma: can be acutely life-threatening, • Majority of renal blunt trauma can account for the largest percentage of renal injuries(90%–95%) • Blunt trauma is usually secondary to motor vehicle accidents, falls,vehicleassociated pedestrian accidents, contact sports,& assault • Renal lacerations & renal vascular injuries make up only 10%–15% of all blunt renal injuries • Isolated renal artery injury following blunt abdominal trauma is extremely rare & accounts for < 0.1% of all trauma patients Diagnosis: • Initial Emergency Assessment Initial assessment of the trauma patient should include: • Securing the airway, • controlling external bleeding, • resuscitation of shock as required • In many cases, physical examination is carried out simultaneous to stabilization of the patient • When renal injury is suspected, further evaluation is required for a prompt diagnosis 10/4/2015 History and Physical Examination History • Conscious patients • Possible indicators of major renal injury: • rapid deceleration event (fall, high-speed motor vehicle accidents) • direct blow to the flank • In assessing trauma patients after motor vehicle accidents: • vehicle’s speed • whether a passenger or pedestrian • Preexisting renal abnormality makes renal injury more likely following trauma: solitary kidney, horseshoe kidneys, stone, hydronephrosis, cyst History and Physical Examination Physical examination • Basis for the initial assessment of each trauma patient.: • Hemodynamic stability: the primary criterion for the management of all renal injuries • Shock: systolic blood pressure< 90mmHg • Vital signs should be recorded throughout diagnostic evaluation • Penetrating trauma: • stab wound: • extent of the entrance wound not accurately reflecting the depth of penetration • lower thoracic back, flanks and upper abdomen, • bullet entry or exit • Blunt trauma to the back, flank, lower thorax, upper abdomen may result in renal injury 10/4/2015 History and Physical Examination Physical examination • The following findings may indicate possible renal involvement: • hematuria, • flank pain • flank ecchymosis and/or abrasions, • fractured ribs, • Abdominal distension or tenderness, and • palpable mass Clinical presentation of renal vein thrombosis depends on: • balance achieved between the rapidity & degree of venous occlusion, as well as the development of collateral veins • patients may be asymptomatic, • no specific symptoms such as nausea or vomiting, • more specific symptoms such as hematuria • flank pain Laboratory Evaluation • Urinalysis, hematocrit and baseline creatinine values: most important tests for evaluating renal trauma • Hematuria: • hallmark sign of renal injury, • neither sensitive nor specific enough for differentiating minor and major injuries • not necessarily correlate with the degree of injury • urine dipstick: acceptably reliable and rapid test • Serial hematocrit determination Initial hematocrit in association with vital signs implies the need for emergency resuscitation • Creatinine measurement reflects renal function prior to the injury( As most trauma patients are evaluated within h after injury) → An increased creatinine usually reflects preexisting renal pathology 10/4/2015 Imaging: Criteria for Radiographic Assessment in Adults • Based on the clinical findings & the mechanism of injury • With microscopic hematuria & no shock after blunt trauma → low likelihood of concealing significant renal injury • Indications for radiographic evaluation: • Gross hematuria, • Microscopic hematuria and shock, or • Presence of major associated injuries, • Rapid deceleration injury Imaging Ultrasonography • Popular imaging modality in initial evaluation of abdominal trauma: quick, noninvasive, low-cost means of detecting peritoneal fluid collections, without exposure to radiation or contrast agents • Color Doppler, power Doppler, or ultrasound with contrast: presence of blood flow to the kidney • Limitations : • Difficulty in obtaining good acoustic windows/trauma patient who has sustained numerous associated injuries • Highly dependent on the operator • Can detect renal lacerations but cannot definitely assess their depth and extent and not provide functional information about renal excretion or urine leakage • Cannot establish if renal function is present, and there is also difficulty in some cases of differentiating a shattered kidney from a congenitally absent kidney 10/4/2015 Imaging Ultrasonography • More sensitive & specific than standard intravenous pyelography (IVP) in minor renal trauma • Serially evaluating stable renal injuries for the resolution of urinomas and retroperitoneal hematomas • Effective screening examination • Suitable for routine follow-up of renal parenchymal lesions or hematoma in ICU Imaging: Standard Intravenous Pyelography • No longer the study of choice for evaluation of renal trauma, • Clearly define the renal parenchyma, & outline collecting system • Non-visualization, contour deformity, or extravasation of contrast implies a major renal injury → further radiological evaluation with CT or less commonly, angiography if available • One-shot IVP in the operating suite: ml/ kg radiographic contrast followed by a single plain film taken after 10 10/4/2015 Imaging: Computed Tomography(CT) • Gold standard method for the radiographic assessment of stable patients with renal trauma, • More accurately defines the location of injuries, easily detects contusions and devitalized segments, visualizes the entire retroperitoneum & any associated hematomas, & simultaneously provides a view of both the abdomen and pelvis • Superior anatomical detail, including: • Depth & location of renal laceration, • Presence of associated abdominal injuries, • Presence and location of the contralateral kidney Magnetic Resonance Imaging • Accurate in finding: • perirenal hematomas, assessing viability of renal fragments,& detecting preexisting renal abnormalities, • but failed to visualize urinary extravasation on initial examination • IV gadolinium-based contrast material → helpful in the assessment of urinary extravasation • Clearly revealed renal fracture with a non viable fragment & able to detect focal renal laceration not detected on CT due to perirenal hematoma • MRI not 1st choice in managing patient with trauma: • Longer imaging time, • Cost, • Limits access to the patient in the magnet during the examination 10/4/2015 10/4/2015 Angiography • CT largely replacing angiography for staging renal injuries, since angiography less specific, more time-consuming, & more invasive • More specific for defining exact location & degree of vascular injuries • Preferable when: planning selective embolization for management of persistent or delayed hemorrhage from branching renal vessels • Define renal lacerations, extravasation, & pedicle injury • Test of choice for evaluating renal venous injuries • Indicated in stable patients to assess pedicle injury, 10 10/4/2015 Diagnosis : Cystography • Retrograde cystography: standard diagnostic procedure • Adequate bladder filling & post void images obtained → accuracy rate 85%–100% • Injected contrast medium identified outside bladder Diagnosis • Excretory Urography (Intravenous Pyelography)” Inadequate for evaluation of bladder & urethra after trauma because of dilution of contrast material within the bladder, & resting intravesical pressure too low to demonstrate a small tear • Ultrasound: peritoneal fluid in the presence of normal viscera or failure to visualize the bladder after transurethral introduction of saline → highly suggestive of bladder rupture • MRI: little place in evaluation of acute bladder • Cystoscopy: • Extremely useful tool in the diagnosis of iatrogenic bladder injuries • Detection rate from 85% to 94.1% indifferent series 23 10/4/2015 Diagnosis: CT Scan CT Scan - not reliable in diagnosis of bladder rupture - intraperitoneal & extraperitoneal fluid but cannot differentiate urine from ascites Treatment • First priority stabilization of patient & treatment of associated lifethreatening injuries Blunt Trauma: Extraperitoneal Rupture • Managed safely by catheter drainage only, even in the presence of extensive retroperitoneal or scrotal extravasation • All ruptures healed in weeks • Involvement of bladder neck presence of bone fragments in bladder wall, or entrapment of the bladder wall → surgical intervention • Presence of open pelvic fractures and/or rectal injuries precludes conservative management due to the high risk of serious infectious complications 24 10/4/2015 Treatment Blunt Trauma: Intraperitoneal Rupture • Always be managed by surgical exploration • Potential risk of peritonitis due to urine leakage, if left untreated • Abdominal organs should be inspected for possible associated injuries,& urinoma must be drained Complications: • Usually the result of failure to diagnose the injury & repair promptly • Urinoma formation, • Urinary leakage into peritoneal cavity → ileus, peritonitis, • Hematoma, • Abscess formation, • Fistula formation (rectal,vaginal,or cutaneous), • Urinary tract infection • Prostatic capsule contains abundant activators of plasminogen & urine contains high levels of urokinase(potent plasminogen activator) → increase & prolong hemorrhage 25 10/4/2015 UrethralTrauma Posterior Urethral Injuries • Posterior urethra Injuries occuring with pelvic fractures (road traffic accidents, crush injuries, or falls from height 26 10/4/2015 Urethral Trauma Stable Pelvic Fracture Unstable Pelvic Fractures 27 10/4/2015 UrethralTrauma Anterior Urethral Injuries Blunt Trauma • Caused by vehicular accidents, falls, or blows • Against the perineum, • Relatively immobile bulbar urethra is trapped & compressed by a direct force on it against the inferior surface of the symphysis pubis 28 10/4/2015 UrethralTrauma Anterior Urethral Injuries Intercourse-Related Trauma • With ruptures of the corpora cavernosa, which usually occur with an erect penis, often during intercourse • Intraluminal stimulation of the urethra with foreign objects • Most short & incomplete & occur in distal penile urethra • Masturbation Usually only corpora • Break cavernosa injured 29 10/4/2015 Clinical Assessment • Blood at meatus(preclude any attempts at urethral instrumentation, until entire urethra adequately imaged) • Blood at vaginal introitus • Hematuria: first voided specimen→urethral injury • Pain on urination/ inability to void • Hematoma/swelling • High-riding prostate 30 10/4/2015 Radiographic Examination • Retrograde urethrography: gold standard for evaluating urethral injury • If posterior urethral injury suspected→suprapubic catheter inserted → simultaneous cystogram & ascending urethrogram (within1week)→ assess site, severity, & length of urethral injury Management: Anterior Urethral Injuries Blunt Injuries • Partial tears: suprapubic catheter or urethral • Cystostomy tube catheterization(maintained for approximately weeks to allow urethral healing.) • Voiding cystourethrography then performed & if normal voiding & no contrast extravasation nor subsequent stricture → tube safely removed • Complications: strictures & infections • Acute or early urethroplasty is not indicated & best management is simply suprapubic diversion 31 10/4/2015 32 10/4/2015 Management: Posterior Urethral Injuries Distinction: between posterior urethral stricture ≠ subprostatic pelvic fracture urethral distraction defect Management: Posterior Urethral Injuries Partial Urethral Rupture • Suprapubic or urethral catheter and repeat retrograde urethrography at 2-week intervals until healing has occurred • Residual/ subsequent stricture • Urethral dilation or optical urethrotomy,(if short & flimsy) • Anastomotic urethroplasty (if denser) 33 10/4/2015 Management: Posterior Urethral Injuries Complete Urethral Rupture • Primary Realignment: either transpubically (open realignment) or with endoscopic techniques (endoscopic realignment) • Primary Open Realignment: associated with concomitant bladder neck or rectal injuries → immediate open exploration, repair & urethral realignment advisable • Primary Endoscopic Realignment: • Patient’s overall condition & extent of associated injuries → decision to proceed with primary endoscopic realignment • Endoscopic urethral realignment may be considered during the first weeks after trauma Management: Posterior Urethral Injuries 34 10/4/2015 Management: Posterior Urethral Injuries Immediate Open Urethroplasty (