A/4. Injuries to the kidney, the ureter and the bladder

Question 1

Kidney injuries

Answer 1

• Blunt trauma (80-90%)
• penetrating injury (10-20%)

Question 2

Kidney injuries grades

Answer 2

Question 3

Dx of kidney injuries

Answer 3

history,
physical examination,
urinalysis,
imaging (CT 1st line)

Question 4

Tx of kidney injuries

Answer 4

ABC approach if critically-ill and unstable,
most blunt injuries are managed conservatively
(grade 3-4 injuries may require surgery, depending on the extent of bleeding and degree of associated injuries)

Question 5

absolute indication for surgery - kidney injuries

Answer 5

• Life threatening hemodynamic instability
• grade 5 injuries

Question 6

do grade 3 and 4 kidney injuries require surgery ?

Answer 6

grade 3-4 injuries ** may ** require surgery, depending on the extent of bleeding and degree of associated injuries)

Question 7

Ureteral injuries etiology

Answer 7

• iatrogenic (surgical procedures; most common),
• blunt trauma,
• penetrating trauma

Question 8

Ureteral injuries Symptoms

Answer 8

No symptoms intially, but days-weeks later:
* moderate-high fever
* flank/abdominal pain
* ureterocutaneous/ureterovaginal fistulas
* paralytic ileus with nausea/vomiting
* urinary extravasation into peritoneal cavity (leads to symptoms of acute peritonitis)
* bilateral ureteral injury
causes postop. anuria and elevated seCr

Question 9

what can lead to symptoms of acute peritonitis

Answer 9

urinary extravasation into peritoneal cavity in ureteral injuries

Question 10

postop. anuria and elevated seCr can be caused by

Answer 10

bilateral ureteral injury

Question 11

Ureteral injuries Diagnostics

Answer 11

• US
• IV urography (delated excretion of contrast material
• hydronephrosis
• contrast extravasation

Question 12

Ureteral injuries treatment depends on

Answer 12

depends on time of diagnosis,
severity,
localization

Question 13

Partial, segmental injury Ureteral injuries treatment

Answer 13

• retrograde or antegrade placement of ureteric stent for 3-4 weeks.
• if it doesnt work : Percutaneous nephrostomy

Question 14

treatment of Complete rupture - ureteral injuries

Answer 14

open or laparoscopic reconstruction

Question 15

Ureteral injuries - procedures used in treatment

Ureteroureterostomy:

Answer 15

Ureteroureterostomy: end to end anastomosis.
Most useful and most applied
method to correct upper and middle part injury

Question 16

Ureteral injuries - procedures used in treatment

Pyeloplasty:

Answer 16

in very high ureteric lesion.
Semicircular anastomosis between
spatulated ureter and pyelon.

Question 17

Ureteral injuries - procedures used in treatment

Transuretero-ureterostomy:

Answer 17

injured ureter (mid or lower part injury) is pulled to one side behind the mesentery and anastomosis is performed on opposite side of
the ureter (end to side)

Question 18

Ureteral injuries - procedures used in treatment
Ureter neoimplantation:

Answer 18

if injury to lower 3rd > reimplantation into bladder

Question 19

Ureteral injuries - procedures used in treatment

Bladder tube flap when is it used

Answer 19

if ureter is shorter

Question 20

-Ureteral injuries - procedures used in treatment
Replacement w/ bowel segment:

Answer 20

• Replacement w/ bowel segment: if extensive loss of ureter

Question 21

Bladder trauma etiology

Answer 21

• Iatrogenic trauma
• or accidental blunt trauma

Question 22

how to assess whether an intraperitoneal or extraperitoneal leak is likely in bladder trauma

Answer 22

As the bladder has intraperitoneal and extraperitoneal components
the degree of bladder distension
at the time of injury determines

Question 23

Diagnostics bladder trauma

Answer 23

• history
• physical examination
• urinalysis (gross hematuria)
• imaging (cystoscopy, CT)

Question 24

Treatment bladder trauma- Blunt extraperitoneal rupture

Answer 24

• Blunt extraperitoneal rupture : conservative with catheter drainage (ensure catheter is NOT blocked by blood clots). Most ruptures heal within 10 days
  *

Question 25

Treatment bladder trauma-intraperitoneal rupture

Answer 25

• may get complicated by peritonitis as a result of urinary leak
• must undergo surgical exploration with repair of the bladder laceration