urologic trauma 1

7/24/2019 Urologic Trauma 1

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Commonly DividedCommonly Divided

1.1. KidneyKidney

2.2. UreterUreter

3.3. BladderBladder

4.4. Urethra andUrethra and

5.5. External genitaliaExternal genitalia



The Primary GoalThe Primary Goal

Preserve the maximal ofPreserve the maximal of

functionalfunctional

inimi!ing the com"licationsinimi!ing the com"lications



I. RENAL INJURIESI. RENAL INJURIES

1.1 to 5# of all trauma cases1.1 to 5# of all trauma cases

5$# of all %U trauma5$# of all %U trauma

Blunt trauma &$ ' ($#Blunt trauma &$ ' ($#

Penetrating trauma 1$ ' 2$#Penetrating trauma 1$ ' 2$#

a)ority grade 1* grade 2 to 5a)ority grade 1* grade 2 to 5+4# of ,lunt - /# of "enetrating+4# of ,lunt - /# of "enetrating

trauma0trauma0



RENAL INJURIESRENAL INJURIES

nitial Evaluationnitial Evaluation

1.1. ematuriaematuria

2.2. Blunt traumaBlunt trauma

3.3. Penetrating trauma Penetrating trauma

a.a. %unshots%unshots,.,. ta, oundsta, ounds




ndications for 6enal magingndications for 6enal maging

1.1. Blunt trauma - %ross hematuriaBlunt trauma - %ross hematuria

2.2. Blunt trauma* micr. ematuria -Blunt trauma* micr. ematuria -

hoc7hoc7

3.3. 8cceleration or 9eceleration in)ury8cceleration or 9eceleration in)ury

4.4. Pediatric trauma "atientPediatric trauma "atient

5.5. 8ssociated in)ury8ssociated in)ury




maging tudymaging tudy

1.1. :; can:; can

2.2. ntavenous urogram +<U0ntavenous urogram +<U0

3.3. U%U%

4.4. 8rteriogra"hy8rteriogra"hy




n)ury caling +88;0n)ury caling +88;0

:ontusion = ematoma:ontusion = ematoma

ematoma = >aceration +ematoma = >aceration + ? 1 cm? 1 cm 00

>aceration +>aceration + @ 1 cm@ 1 cm 00

<< >aceration = <ascular in) - ;hrom,.>aceration = <ascular in) - ;hrom,.

<< >aceration +hattered0 = <ascular>aceration +hattered0 = <ascularavulsionavulsion




ndication for 6enal Ex"lorationndication for 6enal Ex"loration

1.1. Blunt ;raumaBlunt ;rauma +Aig. 10+Aig. 10

a.a. 8,solute indication8,solute indication.. Persistent -Persistent -

"otentially lifethreatening ,leeding"otentially lifethreatening ,leeding

,.,. 6elative indication6elative indication +9evitali!ed +9evitali!ed

"arenchym* Urinary extravasation*"arenchym* Urinary extravasation*incom"lite staging - 8rterialincom"lite staging - 8rterial

throm,0throm,0



Blunt traumaBlunt trauma

Micr. Hematuria

& no shockMicr. Hematuria

& no shock

Renal imaging

Unnecessary exception:

Deceleration or multiple Associated injuries

Renal imaging

Unnecessary exception:

Deceleration or multiple Associated injuries

ross hemat. or

shock !ith micr Hross hemat. or

shock !ith micr H

"#ser$e"#ser$e

Unsta#leUnsta#le %ta#le%ta#le

xploratory laparotomy& single shot '()

xploratory laparotomy& single shot '()

*ormal '()*ormal '() A#normal '()"r inconclusi$e

A#normal '()

"r inconclusi$e

%ta#le retroperitonealhematoma

%ta#le retroperitonealhematoma

)ulsatile expanding"r uncontained

Retroperitonial hematoma

)ulsatile expanding"r uncontained

Retroperitonial hematoma

Renal explorationRenal exploration

A#dominal+, scan

A#dominal+, scan

Associated injuriesRe-uiring laparrotomy Associated injuries

Re-uiring laparrotomy

*o associatedinjury

*o associated

injury

rade ' or ''Renal injury

rade ' or ''Renal injury

grade '''(Renal injurygrade '''(

Renal injury

Renal

explorationRenal

exploration

rade ' / '''Renal injury

rade ' / '''Renal injury

rade '(Renal injuryrade '(

Renal injury

rade (Renal injuryrade (

Renal injury

Renal

explorationRenal

exploration

%electi$e renal

exploration%electi$e renal

exploration"#ser$e"#ser$e"#ser$e"#ser$e "#ser$e"#ser$e




2.2. Penetrating ;raumaPenetrating ;rauma +Aig. 20+Aig. 20

a.a. 8,solute indications8,solute indications

,.,. 6elative indications6elative indications



Penetrating trauma

ematuria or sus"ectCf renal in)ury

Unsta,le or sus"ectedntra"eritonial in)ury

ta,le ith no sus"ectedntra"eritonial in)ury

Ex"loratory la"arotomy- singleshot <P

Dormal <P8,normal <P

Cr inconclusive

ta,le - containedtro"eritonial hematoma

Ex"anding*"ulsatileCr uncontained

6etro"eritonial hematoma

C,servation 6enal ex"loration

8,normal :; scan

%rade renal in)ury

%rade <6enal in)ury

%rade <6enal in)ury

C,servationelective renal

ex"loration6enal

ex"loration




anagementanagement

1.1. urgical methodesurgical methodes

2.2. Dono"erative - :onservativeDono"erative - :onservative




Dono"erative - :onservativeDono"erative - :onservative

1.1. trict ,ed resttrict ,ed rest

2.2. :lose monitoring of <:lose monitoring of <

3.3. ematocritematocrit

4.4.

Broads"ectrum anti,ioticBroads"ectrum anti,iotic5.5. ;ransfusion ;ransfusion

/./. 6eimaging6eimaging




:om"lications:om"lications

1.1. Early com"licationEarly com"lication

2.2. >ate com"lication>ate com"lication



II. URETERAL & RENALII. URETERAL & RENAL

PELVIS INJURIESPELVIS INJURIES8. echanism of n)ury8. echanism of n)ury

1.1. External traumaExternal trauma

2.2. urgical traumaurgical trauma

a.a. Pelvic o"erationPelvic o"eration

,. atrogenic in)uriesin)uries +Urology*+Urology*GynecoloyGynecoloy* :olorectal -* :olorectal -

<ascular surgery<ascular surgery



URETERAL & RENALURETERAL & RENAL

PELVIS INJURIESPELVIS INJURIESB. 9iagnosis of Ureteral n)uryB. 9iagnosis of Ureteral n)ury

1.1. Preo"erative diagnosisPreo"erative diagnosis

2.2. magingmaging

3.3. ntrao"erative diagnosisntrao"erative diagnosis




PELVIS INJURIESPELVIS INJURIES:.:. :lassication:lassication

1.1. >ocation of the ureteral in)ury>ocation of the ureteral in)ury

2.2. echanism - manner of in)ury echanism - manner of in)ury

a.a. >igation>igation

,.,. ;ransection ;ransectionc.c. 8vusion +UPF0* etc8vusion +UPF0* etc




PELVIS INJURIESPELVIS INJURIES9.9. 8ssociated n)uries8ssociated n)uries

1.1. Penetrating ureteral traumaPenetrating ureteral trauma

+($#0+($#0

2.2. Blunt ureteral trauma +#0Blunt ureteral trauma +#0




PELVIS INJURIESPELVIS INJURIES2.2. 9istal Ureteral n)uries9istal Ureteral n)uries

a.a. UreteroneocystostomyUreteroneocystostomy

,.,. <esico"soas hitch<esico"soas hitch

c.c. ;ransureteroureterostomy ;ransureteroureterostomy

d.d. Cther "rocedures Boari Ga"*Cther "rocedures Boari Ga"*renal dis"lacement*renal dis"lacement*

autotrans"lantasionautotrans"lantasion




PELVIS INJURIESPELVIS INJURIES3. idureteral - U""er Ureteral3. idureteral - U""er Ureteral

n)uriesn)uries UreteroureterostomyUreteroureterostomy

4. ;he unsta,le "atient4. ;he unsta,le "atienta.a. :utaneous Ureterostomy:utaneous Ureterostomy

,.,. Ureteral ligation folloed ,y a PDUreteral ligation folloed ,y a PD

c.c. 9enitive reconstruction is9enitive reconstruction isdelayeddelayed




PELVIS INJURIESPELVIS INJURIES5.5. anagement of :om"lic -anagement of :om"lic -

9elayed 9=9elayed 9=

a.a. 9elayed recognition & ' 5#9elayed recognition & ' 5#

,.,. urgically ex"lored - re"airedurgically ex"lored - re"aired

c.c. PD - 9elayed reconstructionPD - 9elayed reconstruction



III. !LADDER TRAU"AIII. !LADDER TRAU"A

&/# ,lunt a,dominal trauma&/# ,lunt a,dominal trauma

($# are associated "elvic fra7tur($# are associated "elvic fra7tur

(1/# of all "elvic fractures(1/# of all "elvic fractures

/$# extra* 3$# intra"eritonial/$# extra* 3$# intra"eritonial

1$12# are com,ined in)uries1$12# are com,ined in)uries



!LADDER TRAU"A!LADDER TRAU"A

8.8. ign - ym"tomsign - ym"toms

1. Dearly all B. ru"t ith1. Dearly all B. ru"t ith hematuriahematuria

2.2. %ross hematuria%ross hematuria

a.a. Blunt in)uryBlunt in)ury ⇒⇒ (51$$#(51$$#

,.,.

Penetrating in)uryPenetrating in)ury ⇒⇒

5$#5$#

3. Pelvic = loer a,d. Pain3. Pelvic = loer a,d. Pain

4.4. na,ility to urinatena,ility to urinate




B.B. 8ssociated n)uries8ssociated n)uries

1.1. (4(# ith associated in)uries(4(# ith associated in)uries

2.2. Pelvic - long ,one fractures*Pelvic - long ,one fractures*

s"inal = visceral in)uriess"inal = visceral in)uries

3.3. ortality rate 1/53#ortality rate 1/53#




:.:. magingmaging

1.1. :ystoga"hy:ystoga"hy

a0a0 Bladder contusionBladder contusion

,0,0 ntestitial ru"turentestitial ru"ture

c0c0

ntra or Extra"eritoneal ru"turentra or Extra"eritoneal ru"ture

d0d0 >arge "elvic hematoma>arge "elvic hematoma

2.2. :; cystogra"hy:; cystogra"hy




9.9. anagement +Aig. 30anagement +Aig. 30

1.1. ntra"eritonealntra"eritoneal - "enetrating- "enetrating

,ladder in)uries,ladder in)uries

2.2. BluntBlunt extra"eritonealextra"eritoneal ,ladder,ladder

in)uries or interstitial ru"turesin)uries or interstitial ru"tures

3.3. Bladder nec7Bladder nec7

4.4. :om"lications:om"lications



IV. URET#RAL INJURIESIV. URET#RAL INJURIES

6elatively uncommon6elatively uncommon

a)ority due to ,lunt traumaa)ority due to ,lunt trauma

9ivided into ant or "osterior9ivided into ant or "osterior

in)uriesin)uries

inimi!e com"licationsinimi!e com"lications



URET#RAL INJURIESURET#RAL INJURIES

8.8. Posterior urethral in)uriesPosterior urethral in)uries

1./(.(# of "elvic fractures1./(.(# of "elvic fractures

:om"lete in 3# - "artial in:om"lete in 3# - "artial in

23#23#

Bladder nec7 or mem,ranousBladder nec7 or mem,ranous

urethral in)ury* direct lacerationurethral in)ury* direct laceration

and distractionand distraction




B. n)ury scaleB. n)ury scale +88;0+88;0

1.1. %rade %rade :ontusion :ontusion

2.2. %rade %rade tretch in)ury tretch in)ury

3.3. %rade %rade Partial disru"tion Partial disru"tion

4.4.

%rade <%rade <

:om"lete disru"tion :om"lete disru"tion

5.5. %rade <%rade < %rade < @ 2 :m %rade < @ 2 :m




:.:. igns - ym"tomsigns - ym"toms

1.1. Blood of the meatusBlood of the meatus

2.2. na,ility to voidna,ility to void3.3. 9istended ,ladder9istended ,ladder

4.4. %ross hematuria* non"al"a,le%ross hematuria* non"al"a,le

"rostate"rostate5.5. Perineal* scrotal or "enile hematomaPerineal* scrotal or "enile hematoma

/./. 9iHculty "assing a Aoley catheter9iHculty "assing a Aoley catheter



URET#RAL INJURIES

9.9. magingmaging studies

1.1. KUB = Pelvic lmKUB = Pelvic lm

2.2. 6U%6U%

E.E. 8ssociated in)uriesin)uries



URET#RAL INJURIES

A.A. %eneral management%eneral management

%oals Preserving%oals Preserving

:ontinence:ontinence

PotencyPotency

8voiding the "elvic hematoma8voiding the "elvic hematoma

infectioninfection



URET#RAL INJURIES

%. :om"lete Urethral 9isru"tion%. :om"lete Urethral 9isru"tion

II :ontroversial I:ontroversial I

1.1. Primary suturingPrimary suturing

2.2. PE6PE6



URET#RAL INJURIES

. Partial Urethral 9isru"tion. Partial Urethral 9isru"tion

II Urinary diversionUrinary diversionJJ



URET#RAL INJURIES

.. Blunt 8nt. Urethral n)uriesBlunt 8nt. Urethral n)uries

1.1. :ontusions:ontusions

2.2. >acerations>acerations

F. F. Penetrating 8nt. Urethral n)uriesPenetrating 8nt. Urethral n)uries

1.1. %unshots%unshots

2.2. ta, oundsta, ounds



$ATETERISASI$ATETERISASI

1.1. DAC6E9 :CDED;DAC6E9 :CDED;

2.2. Prola7sis +8nti,ioti70Prola7sis +8nti,ioti70

3.3. Posisi ;erlentang = >itotomiPosisi ;erlentang = >itotomi

4.4. 9esinfe7si9esinfe7si

5.5. nstillasi >ido7ain)ellynstillasi >ido7ain)elly



;EDK ;EDK

LA$I%LA$ILA$I%LA$I

1.1. Penis 9ilurus7anPenis 9ilurus7an

2.2. asu77an Kateter 9g halusasu77an Kateter 9g halus3.3. Pasien Dafas Pelan -9alamPasien Dafas Pelan -9alam

4. 4. Tekanan halus & kontinyu PdTekanan halus & kontinyu PdSpinter Spinter



;EDK ;EDK

Lai%LaiLai%Lai

asu77an sam"ai Perca,anganasu77an sam"ai Perca,angan

Balon Ai7sasi + 8Luadest 1$ cc 0Balon Ai7sasi + 8Luadest 1$ cc 0

am,ung dg Uro,agam,ung dg Uro,ag

Ai7sasi +nguinal = >i"at Paha0Ai7sasi +nguinal = >i"at Paha0

:atat Urin Mg Keluar:atat Urin Mg Keluar



;EDK ;EDK

'ANITA'ANITA

1.1. >a,ium ayora 9i,u7a>a,ium ayora 9i,u7a

2.2. denti7asi Urethradenti7asi Urethra

3.3. asu77an 7ateter 9g alusasu77an 7ateter 9g alus

4.4. etelah Urin Keluar* ;erus7an 2etelah Urin Keluar* ;erus7an 2

ncinci

5.5. elan)utnya N >a7i>a7ielan)utnya N >a7i>a7i



8dult ,lunt trauma



Do ,lood at meatus Blood at meatus

ay "ass Aoley catheter 6U%

Urology consultematuria Do hematuria

C,serve:; or <P

a)or desc. in)%ross hematuria icrohematuria

<P = :; and:ystogram

C,srve Urology:onsult

hoc7 Do shoc7

<P = :; and:ystogram

PelvicAracture

Do"elvic fracture

:; or <Pa)or desc in)

C,serve:ystogram

C,serve Urology consult

Urology consult C,serve

Dormal



Penetratingn)uries

emodynamicallyta,le

emodinamicallyUnsta,le

C"erating 6oom>oer chestAlan7=,ac7

8,domen

u"ra"u,ic

area

Penis crotum

8,dominal :;

C,servationUrology:onsult

8,dominal :;- :ystogram

C,servation

Urology consult- 6U%

f hematuriaUrology consult

urologic trauma 1

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