Trauma in Urology
( Lecture )Renal injuries
RI account for 1-5% of all traumas BLUNT – car, sport accidents –majority! PENETRATING –gunshots, stab wounds AAST classification (American Associaton for the Surgery of Trauma)AAST classification (American Associaton for the Surgery of Trauma)Contusion, non-expanding subcapsular haematoma, no lacerationNon-expanding perirenal haematoma, cortical laceration < 1 cm deep, no urinary extravasationcortical laceration > 1cm, no u.extravasationLaceration: through corticomedullary junction into collecting system OR vascular: segm. renal artery or vein injury with contained haematomaShattered kidney OR major vascular injury (renal pedicle injury or avulsion)1,2 = minor injuries – 85-95% 3,4,5 = major injuries
Diagnosis
Trauma history, past renal injury, surgery or renal abnormalitiesexamination (haematuria, flank pain, flank abrasions, rib fractures, abd.tenderness) Urinalysis, blood count, creatinine Primary imaging -> USG!! Enhanced abdominal CT !Intraoperative one/shot IVPSecond/line imaging – MRI,Scinti,AngiographyTreatment
WW – grade I-III in stable patientsSurgery (all penetrating injuries, in blunt injuries if: major blood loss, unstable patient, urinary extravasation, nonviable kidney, pedicle avulsion,...)Complications
Early: Haemorrhage, retroperitoneal urinoma, haematoma, abscess Late: Hypertension, AV fistula, calculi, PNF, late bleedingUreteral injuries
Pelvic surgery (uro, gyn, gen.s.) Pelvic/abdomninal masses PID post RT Penetrating injuryClinical findings
Flank pain, tenderness Sepsis Hydronephrosis!! Paralytic ileus VV / UV fistula / watery discharge via vagina/ Labs /CRP,Leu,urinalysis,creatinine/
Imaging
USG IVU / enhanced CT ! APG Radionuclide scanningTreatment
First-line urinary diversion !!! (nephrostomy, ureteral stenting)Reconstructive surgery /reanast., reimpl., substitutions, crossed diversion, autoTPL…/Bladder injuries
direct external force, road accidents iatrogenic / gyn-obs, uro, sur/intraperitoneal disruption extraperitoneal disruption
Clinical findingHaematuria Pelvic , abd. pain (pelvic fracture presented in 90% of bladder inj.) Haemorrhage, Shock Acute abdomen !!! (intraperit)
Imaging
Pelvic & Abdominal USG Cystography (300ml) ! CT cystography
Treatment
Extraperit. – bladder drainage (epi, catheter) Intraperit. – open surgery required!Urethral injuries
Posterior/ Anterior urethraLaceration, transection, contusionExternal forces (falls astride an object, perineal blow, …)Iatrogenic (catheter, uro )Posterior urethra
assoc. w/ pelvic fractures - > prostate avulsion from the membranous u. -> apical displacement of the prostate - > Pelvic urinoma, haematoma DR Exam. ! blood at the urethral meatus !X- Ray (pelvic fracture) Urethrography !!
Treatmentdrainage (suprapubic cystostomy) immediate surgery (suspected bladder lacerations, disruptions, massive pelvic bleeding, etc.) delayed surgery (>3 months after the injury)