A/4. Injuries to the kidney, the ureter and the bladder Flashcards
Kidney injuries
- Blunt trauma (80-90%)
- penetrating injury (10-20%)
Kidney injuries grades
Dx of kidney injuries
history,
physical examination,
urinalysis,
imaging (CT 1st line)
Tx of kidney injuries
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)
absolute indication for surgery - kidney injuries
- Life threatening hemodynamic instability
- grade 5 injuries
do grade 3 and 4 kidney injuries require surgery ?
grade 3-4 injuries ** may ** require surgery, depending on the extent of bleeding and degree of associated injuries)
Ureteral injuries etiology
- iatrogenic (surgical procedures; most common),
- blunt trauma,
- penetrating trauma
Ureteral injuries Symptoms
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
what can lead to symptoms of acute peritonitis
urinary extravasation into peritoneal cavity in ureteral injuries
postop. anuria and elevated seCr can be caused by
bilateral ureteral injury
Ureteral injuries Diagnostics
- US
- IV urography (delated excretion of contrast material
- hydronephrosis
- contrast extravasation
Ureteral injuries treatment depends on
depends on time of diagnosis,
severity,
localization
Partial, segmental injury Ureteral injuries treatment
- retrograde or antegrade placement of ureteric stent for 3-4 weeks.
- if it doesnt work : Percutaneous nephrostomy
treatment of Complete rupture - ureteral injuries
open or laparoscopic reconstruction
Ureteral injuries - procedures used in treatment
Ureteroureterostomy:
Ureteroureterostomy: end to end anastomosis.
Most useful and most applied
method to correct upper and middle part injury
Ureteral injuries - procedures used in treatment
Pyeloplasty:
in very high ureteric lesion.
Semicircular anastomosis between
spatulated ureter and pyelon.
Ureteral injuries - procedures used in treatment
Transuretero-ureterostomy:
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)
Ureteral injuries - procedures used in treatment
Ureter neoimplantation:
if injury to lower 3rd > reimplantation into bladder
Ureteral injuries - procedures used in treatment
Bladder tube flap when is it used
if ureter is shorter
-Ureteral injuries - procedures used in treatment
Replacement w/ bowel segment:
- Replacement w/ bowel segment: if extensive loss of ureter
Bladder trauma etiology
- Iatrogenic trauma
- or accidental blunt trauma
how to assess whether an intraperitoneal or extraperitoneal leak is likely in bladder trauma
As the bladder has intraperitoneal and extraperitoneal components
the degree of bladder distension
at the time of injury determines
Diagnostics bladder trauma
- history
- physical examination
- urinalysis (gross hematuria)
- imaging (cystoscopy, CT)
Treatment bladder trauma- Blunt extraperitoneal rupture
- Blunt extraperitoneal rupture : conservative with catheter drainage (ensure catheter is NOT blocked by blood clots). Most ruptures heal within 10 days
*
Treatment bladder trauma-intraperitoneal rupture
- may get complicated by peritonitis as a result of urinary leak
- must undergo surgical exploration with repair of the bladder laceration
