Trauma in Urology

Trauma in Urology

( Lecture )

Renal injuries

RI account for 1-5% of all traumas BLUNT – car, sport accidents –majority! PENETRATING –gunshots, stab wounds TRUMA TYPE
MINOR 85%
MAJOR 15%


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

❏history: mechanism of injury, past renal injury, surgery or renal abnormalities❏P/E: ABCs, renal vascular injury ––> shock • flank contusions, lower rib/vertebral #, upper abdominal/flank tenderness suggest blunt trauma Urinalysis, blood count, creatinine ❏U/A: hematuria, (> 5 RBC/HPF), degree of hematuria does not correlatewith the degree of injury❏imaging: Primary imaging -> USGEnhanced abdominal CT if patient stable ––> look for renal laceration, urinaryextravasation, retroperitoneal hematoma, and associated intra-abdominal organ injuryIntraoperative one/shot IVP , Second/line imaging – MRI,Scinti,Angiography

Treatment

WW – grade I-III in stable patients• microscopic hematuria + isolated well-staged minor injuries do not need hospitalization• gross hematuria + contusion/minor lacerations: hospitalize, bedrest, repeat CT if bleeding persistsSurgery • absolute indications: hemorrhage and hemodynamic instability• relative indications• nonviable tissue and major laceration• urinary extravasation• vascular injury• incomplete staging• laparotomy for associated injury

Complications

❏outcome• F/U with IVP or CT before discharge, and at 6 weeksEarly: Haemorrhage, retroperitoneal urinoma, haematoma, abscessLate: Hypertension 5%, AV fistula, calculi, PNF, late bleeding

Ureteral injuries

Pelvic surgery (uro, gyn, gen.s.) Pelvic/abdomninal masses PID ureteroscope post RT Penetrating injury Severe blunt trauma, #spine

Clinical 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 scanning

Treatment

First-line urinary diversion !!! (nephrostomy, ureteral stenting)Reconstructive surgery /reanast., reimpl., psas hitch, Boari flap, substitutions, crossed diversion, autoTPL…/


BLADDER TRAUMA❏blunt (MVA, falls, and crush injury) vs. penetrating trauma to lower abdomen, pelvis, or perineum❏blunt is associated with pelvic # in 97% of casesHistory and Physical❏abdominal tenderness and distension, and unable to void❏may be few peritoneal signs or symptoms❏associated injuries such as pelvic and long bone # are common❏hemodynamic instability also common due to extensive blood loss in the pelvis


Investigations❏U/A: gross hematuria in 95% of bladder rupturesImagingPelvic & Abdominal USG Cystography (300ml): extravasation CT cystographyClassification❏contusions: no urinary extravasation, damage to mucosa or muscularis❏intraperitoneal ruptures: often involve the dome❏extraperitoneal ruptures: involve anterior or lateral bladder wall


Management❏depends on the type of bladder injury and the extent of associated injuries❏contusion: urethral catheter until hematuria completely resolves❏extraperitoneal bladder perforations can be managed non-operatively if associated injuries do not require a laparotomy and the urine is sterile at time of the injury• others will need surgical management❏intraperitoneal injuries require drainage and a suprapubic catheterComplications❏mortality is around 20%, and is usually due to associated injuries due to trauma rather than bladder rupture❏complications of bladder injury itself are rare

Urethral injuries

Posterior/ Anterior urethraLaceration, transection, contusionIatrogenic (catheter, uro )most common site is membranous urethra due to blunt trauma, MVAs:• associated with pelvic fractures (10% of such fractures)External forces (falls astride an object, perineal blow, …bulbar urethral injuryother causes: iatrogenic instrumentation, prosthesis insertion, penile fracture, masturbation with urethral manipulation

Posterior urethra

assoc. w/ pelvic fractures - > prostate avulsion from the membranous u. -> apical displacement of the prostate - > Pelvic urinoma, haematoma sensation of voiding without urine output DR Exam.: high riding prostate blood at the urethral meatus !

X- Ray (pelvic fracture) Urethrography !!

Treatment
drainage (suprapubic cystostomy) immediate surgery (suspected bladder lacerations, disruptions, massive pelvic bleeding, etc.) delayed surgery (>3 months after the injury)

Complications after delayed surg.repair

ED 30-35% Incontinence 5% Stricture 5%



Anterior urethra
straddle injury iatrogenic instrumentations self-instrumentations

Clinical findings

perineal, penile, scrotal haematoma…butterfly urethral bleeding normal DRE

Diagnosis

Urethrography: demonstrates extravasation and location of injury do not perform cystoscopy or catheterization before retrograde urethrography if urethral trauma suspected

Treatment

❏simple contusions - no treatment❏partial urethral disruption • with no resistance to catheterization - Foley x 2-3 weeks• with resistance to catheterization• suprapubic cystostomy• periodic flow rates/urethrograms to evaluate for stricture formation❏complete disruption• immediate repair if patient stable, delayed repair if unstablesuprapubic cystostomy

URETHRAL STRICTURE

❏refers only to anterior urethral scarring (posterior strictures not included)❏involves scar in corpus spongiosum❏contraction of this scar will decrease size of urethral lumen❏more common in males

Etiology❏congenital• may cause hydronephrosis• treat at time of endoscopy with dilatation, internal urethrotomy❏trauma• instrumentation (most common, at fossa navicularis)• external trauma • urethral trauma with stricture formation❏infection• common with gonorrhea in the past (not common now)• long-term indwelling catheter• balanitis xerotica obliterans• causes meatal stenosis

Diagnosis and Evaluation❏signs and symptoms• decreased force/amount of urinary stream• spraying• double stream• post-void dribbling• other UTIs (prostatitis, epididymitis)❏laboratory findings• flow rates < 10 mL/s (normal = 20 mL/s)• UA and culture usually negative, but may show pyuria, bacteria❏radiologic findings• urethrogram, VCUG, or ultrasound will demonstrate location❏urethroscopy



Treatment❏dilatation• temporarily increases lumen size by breaking up scar tissue• healing will reform scar tissue and recreate stricture• not usually curative❏internal urethrotomy• endoscopically incise stricture without skin incision• cure rate 70-80% with single treatment, 90% with repeated courses❏open surgical reconstruction• completely excise strictures < 2 cm, extending 1 cm beyond each end• patch graft urethroplasty if > 2 cm• full-thickness skin graft obtained from penis to replace urethra

Scrotal injuries

Scrotal injury: hematocele, testicular disruption, torsion, skin avulsion, traumatic amputationsHEMATOCELE❏trauma with bleed into tunica vaginalis❏ultrasound helpful to exclude fracture of testis which requires surgical repair❏treatment • ice packs, analgesics, surgical repairRupture TestisResult of testicular compression against the pubis bone, from direct blow, or straddle injuriesExtent depends on location of rupture Tunica albuginea ruptures (inner layer of tuncia vaginalis) allows intratesticular hematoma to rupture into hematoceleRupture of tunica vaginalis allow blood to collect under scrotal wall causing scrotal hematomaDoppler often sufficient to assess extentSurgery for uncertain dx, tunica albuginea rupture, compromised doppler flow

Blood as a filling defect in testis

Penile injuries
Penile fracture (sex. intercourse -> disruption of the tunica albuginea -> haematoma, CAVE: urethral injury) Penile constriction – rings Penile amputation